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NAPNAP Position Statement on Access to Care

        The National Association of Pediatric Nurse Practitioners (NAPNAP) is an organization that advocates for children, considers children's health and well-being a priority, and expects that our health care system will improve and maintain the health of America's children. NAPNAP believes that all children should have access to coordinated, comprehensive, and culturally sensitive family-centered care that includes physical and mental health services to promote healthy lifestyles and restore health (
        National Association of Pediatric Nurse Practitioners
        NAPNAP position statement on the integration of mental health care in pediatric primary care settings.
        ). NAPNAP believes that enhanced access to care improves health outcomes and the overall health status of our nation.
        NAPNAP supports the promotion of primary health care as a model that encourages lifelong and comprehensive access to care. Access to care is defined as the timely use of personal health services to achieve the best possible health outcomes, which includes patient access to (a) a usual source of health care, (b) affordable care, (c) a health care provider of choice, and (d) coordinated care between health care providers (
        Agency for Healthcare Research and Quality
        National Health Care Disparities Report (AHRQ Publication No. 11-0005).
        ,
        Institute of Medicine, Committee on Monitoring Access to Personal Health Care Services
        Access to health care in America.
        ,
        • Levesque J.F.
        • Harris M.F.
        • Russell G.
        Patient-centred access to health care: Conceptualising access at the interface of health systems and populations.
        , ).
        Children's health status is influenced by social determinants of health including race, ethnicity, socioeconomic status, physical environment, and health services (
        Centers for Disease Control and Prevention
        NCHHSTP social determinants of health: Definitions.
        ,
        • Cheng T.L.
        • Emmanuel M.A.
        • Levy D.J.
        • Jenkins R.R.
        Child health disparities: What can a clinician do?.
        ). The social determinants of care influence pediatric health care delivery. Communities with high proportions of minority groups are 4 times more likely than other communities to have provider shortages (
        • Flores G.
        • Lesley B.
        Children and US federal policy on health and health care seen but not heard.
        ). Nearly a quarter of the U.S. population lives in rural areas; however, only 10% of physicians practice in these areas. As a result, advanced practice registered nurses (APRNs) are more likely to provide primary health care services, including pediatric care, in rural areas (
        Agency for Healthcare Research and Quality
        Primary Care Workforce Facts and Stats No. 3. (AHRQ Publication No. 12-P001-4-EF).
        ,
        • Graves J.
        • Mishra P.
        • Dittus R.
        • Parikh R.
        • Perloff J.
        • Buerhaus P.
        Role of geography and nurse practitioner scope-of-practice in efforts to expand primary care system capacity: Health reform and the primary care workforce.
        ,
        National Rural Health Association (NRHA)
        What's different about rural health care?.
        ). Although rates of uninsured children have declined since implementation of the Patient Protection and Affordable Care Act (ACA), children who live in poverty remain more likely to be uninsured than those not in poverty (8.6% vs. 5.6%; ). Children who are uninsured have worse health status, delayed immunizations, and higher odds of emergency department visits and avoidable hospitalizations attributed to their lack of access to care (
        • Flores G.
        • Lesley B.
        Children and US federal policy on health and health care seen but not heard.
        ).
        Universal health care insurance is a critical factor for improving the health care of children. Although the percentage of children who are uninsured is declining, more than 5.5 million children remain uninsured (). In 2014, 53.7% of children had private insurance, and 42.2% were enrolled in a public health plan (
        Centers for Disease Control and Prevention
        Health insurance coverage.
        ). The Children's Health Insurance Program (CHIP) was developed to provide health insurance and high-quality primary health care from a usual source of care for eligible children. As of January 2016, 48 states cover children with incomes at or above 200% of the federal poverty level, with 19 states extending eligibility to at least 300% of the federal poverty level (
        • Brooks T.
        • Miskell S.
        • Artiga S.
        • Cornachione E.
        • Gates A.
        Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies as of January 2016: Findings from a 50-state survey.
        ). Further, the ACA's maintenance of effort provision prevents states from making any reductions in children's eligibility through 2019. According to the Kaiser Family Foundation, nearly two thirds (46.4 million of the 70.0 million) of all Medicaid and CHIP enrollees resided in states that have implemented the Medicaid expansion. Children account for a greater share of total Medicaid and CHIP enrollment in nearly all states that have not expanded Medicaid compared with states that have expanded (
        • Artiga S.
        • Rudowitz R.
        • Gates A.
        • Snyder L.
        Recent trends in Medicaid and CHIP enrollment as of January 2015: Early findings from the CMS Performance Indicator Project.
        ). Therefore, advocating for the continuation of children's access to health coverage through Medicaid and CHIP reauthorization is essential to ensure that vulnerable children have access to health care.
        Implementation of the ACA and the expansion of Medicaid enable more Americans to access health insurance, but having insurance is only one step toward receiving care. Access to health care will be out of reach for many American children because of a shortfall in the number of pediatric providers and inadequacy of pediatric provider networks (,

        Odeh, M. (n.d.). Ensuring adequate marketplace provider networks: What's needed for children. Washington, DC: Children's Defense Fund. Retrieved from http://www.childrensdefense.org/library/data/ensuring-adequate-marketplace.pdf

        ). APRNs are essential members of the health care workforce who increase patient access to care (
        Institute of Medicine
        The future of nursing: Leading change, advancing health.
        ).
        Pediatric-focused APRNs practice in diverse settings including primary care, ambulatory care, acute care, specialty care, and long-term care with children in rural and urban areas (
        U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis
        Highlights From the 2012 National Sample Survey of Nurse Practitioners.
        ). APRNs provide cost-effective health care including health education, health promotion, disease prevention, access to community resources, and management during acute and chronic illnesses (
        National Organization of Nurse Practitioner Faculties
        Population-focused nurse practitioner competencies.
        ,
        • Newhouse R.P.
        • Stanik-Hutt J.
        • White K.M.
        • Johantgen M.
        • Bass E.B.
        • Zangaro G.
        • Weiner J.P.
        Advanced practice nurse outcomes 1990-2008: A systematic review.
        ). Many studies have shown that APRNs provide equivalent or superior care compared with physicians in areas of patient satisfaction, rates of hospitalization/rehospitalization, hospital length of stay, ventilator days, and mortality (
        • Newhouse R.P.
        • Stanik-Hutt J.
        • White K.M.
        • Johantgen M.
        • Bass E.B.
        • Zangaro G.
        • Weiner J.P.
        Advanced practice nurse outcomes 1990-2008: A systematic review.
        ,
        • Stanik-Hutt J.
        • Newhouse R.P.
        • White K.M.
        • Johantgen M.
        • Bass E.B.
        • Zangaro G.
        • Weiner J.P.
        The quality and effectiveness of care provided by nurse practitioners.
        ). To ensure that all Americans have access to health care services, all providers must be permitted to practice to the full extent of their education and licensure, which may require federal and state actions to standardize statutes and regulations (
        • Moote M.
        • Krsek C.
        • Kleinpell R.
        • Todd B.
        Physician assistant and nurse practitioner utilization in academic medical centers.
        ,
        • Reagan P.B.
        • Salsberry P.J.
        The effects of state-level scope-of-practice regulations on the number and growth of nurse practitioners.
        ).
        NAPNAP believes it is essential for all children (infants through young adults) to have access to quality, comprehensive health care from a team of pediatric clinicians, including pediatric-focused APRNs, pediatricians, and pediatric subspecialists. Children deserve access to specialized pediatric primary health care, oral care and health maintenance, emergency and acute illness/injury management, chronic illness care, and mental health care.
        To promote access to care, NAPNAP supports the following:
        • 1.
          Initiatives and legislation that (
          National Association of Pediatric Nurse Practitioners
          Health policy agenda.
          )
          • Address financial and nonfinancial barriers to primary care for children
          • Enhance the accessibility to and quality of health care for all children
          • Promote ongoing efforts for reauthorization of Medicaid/CHIP services for children and families as a central resource of coverage
          • Address inconsistencies between states' eligibility criteria
          • Remove regulatory barriers to APRN practice, such as lack of equitable reimbursement, requirements for physician supervision of APRNs, and exclusion of pediatric providers from provider network (
            National Association of Pediatric Nurse Practitioners
            Position statement on reimbursement for nurse practitioner services.
            )
          • Use provider-inclusive terminology (
            National Association of Pediatric Nurse Practitioners
            Position statement on pediatric health care/medical home: Key issues on care coordination, transitions, and leadership.
            )
          • Include APRNs as reimbursable providers and full participants in demonstration projects, reimbursement strategies, and incentive programs (
            National Association of Pediatric Nurse Practitioners
            Position statement on pediatric health care/medical home: Key issues on care coordination, transitions, and leadership.
            )
          • Improve health care communication technology, including the electronic health record, for seamless communication between providers supporting coordination of care
        • 2.
          IOM recommendations, including but not limited to (
          Institute of Medicine
          The future of nursing: Leading change, advancing health.
          )
          • Allowing APRNs to practice to the full extent of their education and training with decreased variances between state regulations on practice
          • Supporting nurses in achieving higher education and training in an enhanced education system facilitating academic progression
          • Supporting nurses as full partners with physicians and other health care professionals in redesigning health care in the United States
          • Ensuring pediatric nursing content in undergraduate education and subspecialty educational opportunities for pediatric-focused APRNs
          • Expanding nurse leadership positions through increased appointments to key decision-making and board positions
        • 3.
          Healthy People 2020 objectives to improve the health, well-being, and safety of adolescents and young adults and to decrease their risk of developing preventable diseases/morbidities of adulthood (
          U.S. Department of Health and Human Services
          Healthy People 2020: Adolescent health.
          )
        • 4.
          Culturally sensitive public health outreach education programs and research targeted to address social determinants of health care
        • 5.
          Collaboration of private and public funds to support advanced research and high-value innovative solutions to provide improved access to health care
        • 6.
          Efforts to evaluate the benefits of Medicaid and CHIP, improved health insurance coverage for eligible children and an increase in the number of eligible children, and promoting children's access to high-quality pediatric health care providers
        • 7.
          Legislation allowing parents the right to choose a pediatric health care provider
        • 8.
          Efforts to increase access to quality pediatric emergency and specialty care at local, state, and federal levels (
          • Basco W.T.
          • Rimsza M.E.
          Pediatrician workforce policy statement.
          , ,
          • Sullivan A.F.
          • Rudders S.A.
          • Gonsalves A.L.
          • Steptoe A.P.
          • Espinola J.A.
          • Camargo Jr., C.A.
          National survey of pediatric services available in US emergency departments.
          )
        NAPNAP is an organization whose mission is to empower pediatric-focused APRNs and their interprofessional partners to enhance child and family health through leadership, advocacy, professional practice, education, and research and believes that all children should have access to comprehensive health care services through the provision of insurance to the uninsured and choice in the selection of health care providers for quality care.
        The National Association of Pediatric Nurse Practitioners would like to acknowledge the contribution of the Professional Issues and Health Policy Committees and the following members for their contribution to this statement: Beth Heuer, DNP, RN, CPNP-PC, PMHS (Chair, Professional Issues Committee); Kristin Gigli Hittle, MSN, RN, CPNP-AC, CCRN; Raji Koppolu, MSN, CPNP-PC/AC; Jill Ariagno, MSN, RN, CPNP; Megan Connelly, DNP, APRN-NP, CPNP-AC, CNML, CCRN; Imelda Reyes, DNP, MPH, CPNP, FNP-BC.

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