Guidelines for Collaborative Practice for the NJ Advanced Practice Nurse 

 Developed by the Forum of Nurses in Advanced Practice of the New Jersey State Nurses Association

 Purpose of these guidelines

These guidelines have been developed to provide a resource for advanced practice nurses (APNs) and their collaborators in the state of New Jersey. Though information about each step in the formation and continuation of collaborative practice is provided, realize that elements of this information may change as statutes pass, regulations are adopted and APN scope of practice expands over time. Please re-check this site periodically for updates to the guidelines.

 Collaborative practice

In the state of New Jersey, APNs are independently certified providers but they are required to prescribe medications and devices in accordance with a statutorily-mandated joint protocol which has been cooperatively agreed upon and signed by the APN’s designated collaborating physician. Health care, health education, and illness prevention are provided by health professionals of varied backgrounds. When APNs and Physicians work together, their combined skills and backgrounds are complimentary and enhance care. Accessibility, cost effectiveness and improved quality of care are demonstrated by research to be the strong positive outcomes of MD/APN collaborative efforts. Each member of the health care team functions within her/his scope of practice using developed guidelines and established formularies where appropriate.

 Legal Authority

Authority for APN practice is delineated in the Nurse Practice Act: 45:11-45 et seq and related Board of Nursing Administrative Code: 13: 37-6.3 and 13:37-7.1-7.11., a copy of which can be obtained from the New Jersey State Board of Nursinghttp://www.state.nj.us/lps/ca/medical/nursing.htm  page down to RULES, click on NURSING REGULATIONS.

To apply for New Jersey State APN certification, you need:

From the State Board of Nursing:

From your school:

From your national certification board:

This process is outlined in Statutes and Regulations, Board of Nursing (look at the above links). RN licensure and APN state certification must be renewed biannually. A renewal envelope is sent from the NJ Board of Nursing prior the expiration date on your RN license and your APN certificate. Respond immediately since you are not legally permitted to practice in the state without a current RN License and a current APN certificate.

Joint Protocols for Prescribing

In New Jersey, a joint protocol is a state- mandated written document that describes the guidelines for prescribing medications and devices for an APN in a specific practice setting; this joint protocol must be cooperatively agreed to and signed by the APN and her/his designated collaborating physician. It must be reviewed, updated and co-signed, at least annually. Though the particular language in the joint protocol may vary from practice to practice, each joint protocol must follow the outline defined by New Jersey state Board of Nursing regulations at 13:37-6.3http://www.state.nj.us/lps/ca/nursing/nurjon.htm. For an example of how the joint protocol can be written go the NJSNA website http://www.njsna.org/suggested_template.htm

Prescriptive Authority

• This authority is a legislated privilege. The State of New Jersey has authorized prescriptive authority for APNs certified in the state. To prescribe in the state of New Jersey, current NJ licensure as a registered professional nurse and current NJ certification as an Advanced Practice Nurse are required by the State Board of Nursing.
• Prescriptions for non-controlled drugs and devices can be ordered by certified APNs in conformity with provisions of the law utilizing annually updated joint protocols.
• In order to prescribe Class II-V controlled substances as is allowed by law, the APN must first obtain a controlled and dangerous substances (NJ CDS) license numberhttp://www.njconsumeraffairs.gov/drug/dchome.htm. Once this is received, the APN must apply for a Federal Drug enforcement agency (DEA) number www.deadiversion.usdoj.gov.
• Remember to present these certificates to credentialing committees in the facilities where you work for approval prior to prescribing controlled substances.

Prescriptions

Uniform prescription blank pads, specifically designed for an individual APN prescriber, and printed on special paper are required by NJ statute to help prevent changes to the prescription after it has been written. A list of state approved vendors from which APNs can order pads is listed athttp://www.state.nj.us/lps/ca/nursing/apncert.htm#prescriptive.   Scroll down to approved vendors.

NPI#s: Consistent with Federal Center for Medicare and Medicaid (CMS) requirements as of 5/07, the NPI is now the recognized national provider identifier and since pharmacists will now be asking it of providers, the NJ Prescription Blank Unit is requiring that APNs put it on all prescriptions. You may use old prescription pads and hand write it in until 9/30/08; when ordering new pads, vendors are aware they must make a space for the NPI. If you do not have an NPI# you can obtain one by going to: https://nppes.cms.hhs.gov/NPPES/Welcome.do 

By October 1, 2008, the Prescription Drug Unit requires that all NJ prescribers have the NPI# preprinted on the prescription pads and that all prescription pads be serialized by the vendor.

Prescription for all medications/devices must include:

§         Prescriber’s full name, address, telephone number, APN certification #, NPI#. (It is acceptable to use old pads and write in the NPI# until 9/30/08; by 10/1/08, it must be preprinted and the pad must be serialized by the vendor).

§         Space for the APN’s DEA# (The NJ Prescription Drug Unit recommends that it not be preprinted on the pad).

§         State mandated title: APN. and academic degree(s), if desired, before the APN (Example, Susan Smith, MSN,APN)

§         Full name, address, phone, degree and license number of collaborating physician

§         Full name, age and address of the patient

§         Date of issuance of prescription

§         Name strength route and quantity of the drug

§         Adequate instructions

§         Number of refills permitted

§         Signature of APN prescriber followed by APN. (no other titles are permitted in this space).

Suggestion: Look at a copy of a presently practicing APN’s prescribing pad to view the finished product; note also that a change in regulation now allows the APN title font to be bigger (9) than the collaborating physician title font (7) on the pad; request that difference from the vendor since it makes your name more visible/accessible to the consumer for whom you have prescribed.

Prescriptions for controlled substances must additionally include:

§         DEA number of the APN (Do not have this pre-printed on the pads; leave blank after DEA of APN).

§         No more than one CDS medication per prescription blank:

 APNs can prescribe CDS using the 2004 statute (that is, without restriction) if, as per new APN regulations adopted June 16, 2008 (and available on FNAP website, right column, bottom) if they have:

APNs, must of course, have both an NJ CDS# and a Federal DEA# before prescribing CDS.

Approved prescription pad vendors are listed on BON website (http://www.state.nj.us/lps/ca/nursing/apncert.htm#prescriptive); vendors are aware that the new pads need no longer have the former boxes (restricting type of controlled substance prescribing) and that the APN’s name should be printed larger than the collaborating physician’s.

For a copy of the new APN statutory law go to: http://www.njsna.org/displaycommon.cfm?an=1&subarticlenbr=18 

For all APNs who have taken the controlled substance prescribing course: you don’t have to take it again (it is a one-time course); for those who haven’t taken it, there is still time. It is offered on an continuing basis by UMDNJ School of Nursing.  Check the UMDNJ website at http://sn.umdnj.edu.

Initiating Collaborative Practice-

Position Description - In addition to joint protocols, the APN and collaborator should develop guidelines that clearly delineate roles and responsibilities. Periodic review will allow opportunities for updating. Both parties should be clear on consultation guidelines and limitations of practice by state law and level of expertise.

Contract - A contractual agreement is not mandatory but may prevent misunderstandings. Items could include: responsibilities, salary, personal time off (vacation, sick time et al) sponsoring and providing paid time for continuing education, educational resources, and perks (i.e. journals, conferences, malpractice insurance, life insurance, medical insurance, dental insurance, retirement benefits, profit sharing, et al). Remember that 30 Contact Hours in Continuing Education are required for APN re-certification biannually. These contact hours need not be exclusively pharmacologically related; the requirement is that the education be related to the APN’s practice and include pharmacology.

Malpractice/Liability Insurance - Malpractice insurance is necessary for practice. Experts strongly advise personal professional coverage, in addition to any coverage provided by your employer. Coverage is advised at a minimum of $1million: $3 million. Some suggested insurers (listed here, but not endorsed by this document) include: Marsh and Company, endorsed by the American Nurses Association and provides discounts to members: http://www.proliability.com; Nursing Service Organization: http://www.nso.com; Cotterell, Mitchell and Feifer: http://www.cmfgroup.comTypes of liability insurance include incident or tail coverage. Be sure you understand the different types of coverage prior to buying a policy.

Integration into Practice - Staff and patients should be informed that the addition of an advanced practice nurse will enhance services. Copies of articles that support the use of professionals can be given to staff and patients. A fact sheet on APNs is available fromhttp://www.njsna.org/displaycommon.cfm?an=1&subarticlenbr=132.  Brochures describing advanced practice nursing can be obtained from the American Academy of Nurse Practitioners (AANP) http://www.aanp.org. Both the nurse and the physician need to discuss how patients will be introduced to the concept. Patients may be given an option to designate who they see or may be automatically directed to a specific care provider, depending on type of visit.

Hospital Privileges/Facility Credentialing - Credentialing is the process of granting authorization to provide care and treatment in an institution. In NJ, some hospitals allow APNs to admit, visit and discharge patients while others grant APNs only visitation rights. The process of applying for privileges varies from institution to institution and can be relatively unstructured or extremely rigid. Talking to other practitioners who have gone through the process at your institution or seeking information from APNs working at other hospitals in the state, like Robert Wood Johnson-University-or Jersey Shore University Medical Center where APNs have long been credentialed-may be helpful . If you are an initial applicant, officers of the Forum of Nurses in Advanced Practice (FNAP) of the New Jersey State Nurses Association (NJSNA) may be helpful in this regard, click here for the Officers.  You or a collaborating physician may meet with the chair of the hospital credentialing committee to obtain information on the current status of advanced nursing practice privileges.

Reimbursement

Reimbursement can be obtained directly as an APN in New Jersey from Medicare, NJ Medicaid, and a growing number of private insurance companies. Direct reimbursement is granted when services are provided to members of the uniformed services and their families under the Civilian Health and Medical Program of the Uniformed Services Act and federal employees under the Federal Employee Health Benefit Plan.

All APNs should obtain and use their own Medicare number. When this is done, Medicare reimburses approved services at 85% of the rate paid to the physician for similar service. APNs can also seek reimbursement “incident to” the physician and obtain reimbursement at a 100% rate. However, this is not recommended since Medicare has become extremely strict about having the physician physically present and directly involved in any care billed “incident to” and an alarming number of cases now exist where Medicare has successfully ordered practices to repay them when “incident to” services did not occur exactly as required.

Medicaid is a federal program under state control and NJ, at this time, reimburses APNs at 85% of the physician rate.

An increasing number of third party payors do credential APNs as providers of patient care. These currently include: Horizon, Oxford, Qualcare, United Healthcare, Horizon Mercy and Magellan Behavioral Health. Most HMOs who do not directly credential APNs as providers, will still allow the APN to bill for services under the collaborating physician’s provider number. This is not the most desirable situation, since it means that APNs remain “ghost” providers, but it may nevertheless be the most practical road to take with some of the private insurance companies. (Among the HMOs, Aetna has been most strict about officially requiring that the physician be “directly” involved in some level of care if the APN plans to seek reimbursement under the physician’s number).

• Medicare (Empire Medicare Services): 1-866-309-0486
• Medicaid (NJ Medicaid): 609-588-6036
• Apply to Private 3rd party payors individually for reimbursement as a provider.

To effectively bill third party payors, APNs must have a working knowledge of :

• ICD-9 coding information. Available athttp://www.aafp.org/online/en/home/publications/journals/fpm/icd9.html
• CPT coding information. Available at AMA’s free CPT/RVU Search on their CPT Manual Site:http://www.ama-assn.org/ama/pub/category/3113.html.An excellent resource regarding billing questions for APNs can be found at http://www.medscape.com/viewarticle/422935

Collaborating physician changes - When your collaborating physician changes you will need to:

• Revise your joint protocol with new collaborating physician signature.
• Obtain new prescription pads with new collaborating physician name/address/NJ license number. New pads take about 2 weeks to receive.
• Notify NJ CDS (if you have a CDS number) if your practice site changes; they do not require notification that the name of your collaborating physician has changed unless your practice site has also changed. The CDS license has contact information.
• The New Jersey State Board of Nursing does not record either collaborating physician names or practice sites so it is not necessary to contact them.

Preceptorship - Once you have been practicing for two years, you may be approached by a student nurse practitioner or faculty member to precept. This is not a small responsibility. The following guidelines are suggested:

• Request courses or texts on teaching, learning guidelines unless you are an educator. Many excellent clinicians have had no exposure to educational philosophy and knowledge.
• Discuss legal liability and malpractice.
• Obtain a profile of the student’s background, performance to date and skills attained. Be very clear on what the student can do unsupervised and what must be observed.
• Confer or meet regularly with the student’s faculty member. Lack of acceptable progress must be communicated to the faculty member, who will then follow up with the student.
• Read basic texts and articles on the subject. See reference list below.

Networking/Peer support - The NJ State Nurses’ Association (NJSNA) encourages all APNs to join the Forum of Nurses in Advanced Practice (FNAP) a group formed by APNs within NJSNA to help meet the political, educational and practice needs of APNs. The Forum holds regular business meetings four times a year http://www.njsna.org/displaycommon.cfm?an=1&subarticlenbr=130. These meetings provide timely information on a variety of topics pertinent to APNs in New Jersey. Continuing education offerings are provided at each meeting. There is also ample opportunity to network, share experiences, and gain support from peers. Information on volunteer opportunities within the Forum is available. Committees include:

• Professional Education
• • Continuing Education
  • Convention Program
• Professional Affairs
• Legislative Affairs
• Publicity
• Publications
• Nominations

Other advance practice groups that meet regularly in New Jersey-

• NJSNA/FNAP Chapters
• • Northern Chapter
  • Southern Chapter
  • Ocean-Monmouth Chapter
  • Elmer Chapter
• College of Midwives www.midwife.org
• National Association of Pediatric Nurse Practitioners (NAPNAP) www.napnap.org
• Society of Psychiatric APNs (SPAPN) http://www.spapn.org
• American Academy of Nurse Practitioners (AANP) www.aanp.org
• American College of Nurse Practitioners (ACNP) http://www.acnpweb.org/i4a/pages/index.cfm?pageid=1

Resources:

The New Jersey State Nursing Association is the organization that advocates, supports and lobbies for all nurses including APNs in New Jersey.

New Jersey State Nurses Association
1479 Pennington Road
Trenton, New Jersey 08618
Tel. 1-609-883-5335
www.njsna.org

Answers to: Frequently Asked Questions re. APN Practice can be found here.

 The New Jersey State Board of Nursing is the government regulating agency that licenses APNs. It advocates for consumers.

New Jersey State Board of Nursing
124 Halsey St.
Newark, New Jersey 07102
Tel. 1-201-504-6430
Mailing Address:
PO Box 45010
Newark, New Jersey 07101
http://www.state.nj.us/lps/ca/medical/nursing.htm

The Advanced Practice Nurse Listserve, is a useful tool for NJ APNs: learn how to join and about the list serve at http://www.njsna.org/displaycommon.cfm?an=1&subarticlenbr=270

References

• American Journal of Nursing (2000). Study in JAMA shows nurse practitioners provide quality primary care on par with physicians. News& Views, (1),5.
• Anonymous (2002). Getting to “yes”: the art of negotiation. Nurse Practitioner, Supplement 44-5.
• Board of Nursing Statutes and Regulations, NJ Department of Law and Public Safety, January, 2004.
• Brooton, DN, York, R, Brown, LP, Munro, BH, Hollingsworth, AO, Cohen, SM, Finkler, S, Deatrick, J & Youngblut, JM (2002). Lessons learned from testing the quality cost model of advanced practice nursing (APN) transitional care. Journal of Nursing Scholarship, 34(4), 369-375.
• Brent, NJ (2001). Nurses and the Law. 2nd ed. Philadelphia: Saunders.
• Buppert, C (1997). Employment agreements: clauses that can change an NP’s life. Nurse Practitioner, 22(8): 108-9, 112,