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Winter 2016 • Kentucky
Nurse Practitioners and
Nurses in Public Heath
By Rice Leach, M.D.
Public Health nurses have
been an integral part of the
health team for decades
especially in patient homes
and schools and in public
health emergencies. They acted on behalf of
the health officer and were an extension of
physicians’ offices. They still do that work
but their role expanded considerably in
1988 when the Kentucky General Assembly
amended the Kentucky Revised Statutes to
enable local health departments to be reimbursed by Medicaid for preventive health
services provided by directly by registered
nurses and used Medicare rates for services
provided by advanced nurse practitioners.
Those changes occurred because many
Medicaid eligible women and children and
uninsured people had trouble finding preventive, screening, communicable disease
and chronic disease services. The lack of
access was also a compliance issue because
the United States had created a Medicaid
entitlement for beneficiaries that Kentucky
was not always able to meet.
The General Assembly transferred some
state general funds from the Department for
Public Health budget to the Medicaid budget to take advantage of the federal match
and authorized the Cabinet for Human
Services to establish a delivery system with
appropriate standards of care, training for
registered nurses, quality control, and signed
standing orders and oversight by a qualified
local physician. The Kentucky Department
for Public Health arranged appropriate training for registered nurses and nurse practitioners in prenatal care, well child care, sexually
transmitted diseases, tuberculosis, breast
and cervical cancer screening, childhood
immunizations, family planning and other
preventive services. Registered nurses follow
specific and detailed protocols approved
by the state and a local physician and teams
from the Kentucky Department for Public
Health use chart review and on-site consultation for quality assurance. Also each health
department has arrangements with its local
medical care community for further assessment and treatment of positive findings
like abnormal laboratory findings, possible
tuberculosis and for labor and delivery for
pregnant women.
This law enabled both local health
department registered nurses and nurse
practitioners to be independent practitioners because the new rules did not
require a physician to be in attendance to
bill Medicaid. Health Department revenue
increased substantially, the ranks of registered nurses expanded, school nurse presence in public schools expanded, over one
million patients were able to get preventive
services close to home and the state met its
obligation under the Medicaid entitlement.
Beyond those direct patient benefits, this
law enabled Kentucky public health departments to demonstrate that nurses and nurse
practitioners can act independently and
collaboratively, including dispensing from
an approved drug formulary, when a proper
system is in place. Finally, it gave Lexington’s
only public health physician H