Author: Brooke Trainum

Brooke Trainum is the Director, Policy and Regulatory Advocacy in ANA’s Department of Policy and Government Affairs where she works on emerging issues related to health systems, telehealth, and regulatory policy. In this capacity she collaborates with external and internal stakeholders to contribute to policy statements, regulatory comments, and legislative testimony. Passionate about improving health outcomes through policy and best practices, Brooke has worked in both the United States and Internationally in a variety of clinical, public health, and policy settings; collaboratively working to transform individual and community health. Brooke holds a juris doctor, with a certificate of International law, from the University of Denver, Sturm College of Law and a bachelors of science, in human nutrition, foods, and exercise, from Virginia Tech.

Congressional and Judicial Actions Addressing Border Conditions

  

By Brooke Trainum and Janet Haebler

As we celebrate America’s birthday and the freedoms we enjoy, recent headlines remind us that others’ have not been as fortunate. The July 4th holiday comes right after a federal judge’s order to US Customs and Border Protection (CBP) addressing concerns in detention facilities holding refugees. On June 28th, a federal judge in Texas ruled that “CBP must permit health experts into detention facilities holding migrant children to ensure they’re ‘safe and sanitary’ and assess the children’s medical needs.” This order is only applicable in the El Paso and Rio Grande Valley regions, due to the subject of the lawsuit. Judge Dolly Gee gave the Trump administration a deadline of July 12th to report what they have done to correct the conditions. This ruling is on the heels of Secretary of Health and Human Services Alex Azar stating in an interview shared by Politico that “the centers run by CBP were not good conditions for kids to be in.”

The situation at the border is complex in nature and for many that can lead to a feeling of helplessness and despair. ANA has repeatedly expressed concerns with the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS) and Congress, most recently via a June 2019 letter sent to DHS. Additionally, Congress recently passed emergency supplemental funding to help alleviate this situation. Given the complexities of this issue there was even disagreement within the political parties on how to address this crisis.

The reports coming from these detention facilities are unfathomable. There are two main government agencies that oversee refugee shelters, with both DHS and HHS each carrying a different mission. The Office of Refugee Resettlement (ORR) within HHS is specifically responsible for unaccompanied minor children; however, it has been the facilities overseen by DHS and CBP that has made the news most recently as having unsafe, unsanitary, and inhumane conditions.

What many do not realize is the unacceptable conditions of border detention facilities is not new. Greater media attention has highlighted the situation. Accommodations erected decades ago were intended for single males, not families. The situation has been exacerbated by a backlog in the immigration court system. Under standard procedures, detention is intended to be for a short duration, not exceeding 72 hours, while claims for asylum are received and processed. Yet, it has been reported that in mid-2019, the average length of detention exceeded one week. In May and June 2019, between 14,000 and 18,000 people were held by CBP each night. And yet another confounding factor is that several of the detention facilities housing refugees are operated by private corporations who have contracts with Immigration and Customs Enforcement (ICE).

While many agree that immigration laws need to be reviewed and modernized, this is an issue where many Americans are split on the solution. Due to this divide, ANA has focused on the immediate issue of a humanitarian crisis affecting the health and well-being of those impacted at the border. As nurses, we have a duty through the Code of Ethics for Nurses to speak out and advocate for the human rights and health care needs of all, particularly the most vulnerable.

ANA works to ensure nurses are equipped to treat their patients’ pain effectively

  

As the largest healthcare provider group in the country, nurses are no strangers to treating pain, including chronic, acute, and emotional pain. Nurses are also subject to their own personal pain, and they are not alone. Today, there are approximately 50 million adults in the US living with chronic pain and over a third of those adults’ pain interferes with their daily activities. ANA is monitoring and advocating along with our nursing partners, around the Department of Health and Human Services Pain Management report due to be finalized later this year, that promises to help providers use evidence based treatments to manage their patients’ pain while considering the nationwide opioid epidemic.

In 2011, the Institute of Medicine recommended that pain and relieving pain should be a national priority. The report goes on to say that pain is a chief driver for visits to physicians and other healthcare providers, a major reason for taking medications, a major cause of disability, and a key factor in quality of life and productivity. We have all experienced pain and for many, if not all nurses, we have had to decide how and to what degree to treat that pain.

The Code of Ethics for Nurses with Interpretative Statements (the Code) mandates that nurses have an ethical obligation to treat their patients’ pain without bias. To minimize biases, the nurse must identify the influences and intentionally set them aside. However, the Code does not say how they must treat pain. For many what first comes to mind is treatment that involves opioids. For some diagnoses, opioids are part of the best clinical practices for treatment; for others, it may be a combination of pharmacological, restorative, and alternative therapies. Patient adherence, access, coverage, and social determinants may all affect the best option for the individual.

More recently, there has been a renewed interest in the role of pain with regards to the opioid epidemic. Pain is a separate disease from the addiction and dependence that can come from opioid use, a fact which has been recognized by the Department of Health and Human Services Pain Management Best Practices Inter-Agency task force. Encouraging to nurses, the task force recommends an individualized and multidisciplinary approach to chronic pain that also includes increased insurance coverage for Complex Management Situations. It also calls for safer opioid stewardship through a risk assessment based on the patients’ medical, social, and family history.

Nurses are also positioned to provide care coordination activities for improved patient outcomes to patients and their families suffering from chronic pain conditions and associated co-morbidities. ANA commented on the draft pain management report and will continue to advocate the role of nursing in treating chronic pain to the task force and agency. The task force will meet on May 9th and 10th to vote on final recommendations.

Recognizing pain as not just a symptom, but rather a disease for some patients, may help shape the patient-provider relationship and higher quality outcomes of care. Pain can have devastating personal, financial and social consequences. Reshaping how nurses talk about pain with their patients and taking the time to learn about and advocate for alternative therapies available in the community, can help in the immediate care of a patient and the long-term ability to complete activities of daily living.

The Medicare Payment Advisory Commission makes recommendations for APRNs

  

The value of nurses continues to be seen at the federal level. Paralleling the Administrations’ December report, that recognized the role registered nurses and advance practice registered nurses (APRNs) play in patient care, the Medicare Payment Advisory Commission (MedPAC), also made recommendations to show the value of nurses. At the most recent MedPAC meeting in January, the 17 commission members, including two nurses, unanimously voted to recommend that “The Congress should require APRNs and Physician Assistants (PAs) to bill the Medicare program directly, eliminating ‘incident to’ billing for services they provide.” The goal of this recommendation is to reduce costs in the Medicare program as well as improve Medicare’s data on who furnishes care to beneficiaries. Currently, APRNs and PAs are paid 85 percent of the rate that physicians receive under the physician fee schedule when they bill Medicare directly for the same services. Therefore, practices may be reimbursed less overall, but accurate data can be collected to show the value of nursing.

The second recommendation from the Commission reads that, “The Secretary [of Health and Human Services] should refine Medicare’s specialty designations for APRNs and PAs.” Medicare has limited information on the specialties of practice for these clinicians and therefore cannot target resources appropriately to areas of concern, such as primary care.

It is important to note that nothing in either of the recommendations would determine what services clinicians can perform, which is up to state statutes and the physicians with whom they practice. MedPAC can only make recommendations to Congress for consideration to changes to the Medicare system.

These recommendations closely parallel the Administration’s Reforming America’s Healthcare System Through Choice and Competition Report that endorses broader state and federal scope-of-practice (SOP) statutes for all health care providers, including APRNs, that allow them to practice to the top of their license and full skill set. The report also advises eliminating “collaborative practice” and supervision requirements which can impede access to care and limit the ability of providers to diagnose and treat myriad health care issues, especially in underserved populations and in rural areas where patients rely on APRNs for timely care and lifesaving treatment.

Individual states will have to determine SOP statutes, but if all APRNs who bill Medicare are designating their areas of practice as well as services provided, increased data will be available to better determine patient outcomes and highlight quality nursing services. Moreover, better data will be available for services provided by communities to allow for more informed choices at the local and state level.

ANA continues to participate in discussions regarding APRN SOP and has provided comment to MedPAC and the Administration on issues, such as expansion of telehealth services to Medicare beneficiaries, that can affect nurses and the care they provide to patients across the country.