Senate Committee on Health and Human Services (02/19/2009)

Final
STAFF SUMMARY OF MEETING

SENATE COMMITTEE ON HEALTH AND HUMAN SERVICES

Date:	02/19/2009	ATTENDANCE

Time:	01:36 PM to 03:42 PM	Carroll M.	X
		Lundberg	X
Place:	SCR 356	Mitchell	X
		Morse	*
This Meeting was called to order by		Newell	X
	Senator Boyd	Schultheis	E
		Tochtrop	*
This Report was prepared by		Boyd	X
	Elizabeth Burger
		X = Present, E = Excused, A = Absent, * = Present after roll call

Bills Addressed:		Action Taken:
Conf 09-Commission for the Deaf and Hard of Hearing Conf 09-Colorado Traumatic Brain Injury Board Sunset Review of the State Board of Nursing		Favorably Refer to the Full Senate Favorably Refer to the Full Senate -

01:37 PM

Although Senator Schultheis was noted as "absent" throughout the meeting, he was, in fact, excused for the meeting, and the record was changed to reflect this fact.

Leslie Ralphe, Jennifer Peterson, Dr. Barbara Jenkins, and Shelley Strickfaden, appointees to the Colorado Commission for Deaf and Hard of Hearing, discussed their backgrounds and interest in serving on the commission. Copies of their resumes and appointment letters were distributed to the committee (Attachment A). Ms. Strickfaden distributed a handout to the committee (Attachment B). Various committee members commented on the appointments.

(Attachment A can be viewed at State Archives)

(Attachment B can be viewed at State Archives)


BILL:	Conf 09-Commission for the Deaf and Hard of Hearing
TIME:	01:46:02 PM
MOVED:	Carroll M.
MOTION:	Refer the appointments of Leslie Ralphe, Jennifer Peterson, Dr. Barbara Jenkins, and Shelley Strickfaden to the Colorado Commission for the Deaf and Hard of Hearing to full Senate for confirmation. The motion passed on a 6-0 roll call vote, with two members excused.
SECONDED:
		VOTE
	Carroll M.	Yes
	Lundberg	Yes
	Mitchell	Yes
	Morse	Yes
	Newell	Yes
	Schultheis	Excused
	Tochtrop	Excused
	Boyd	Yes

Final YES: 6 NO: 0 EXC: 2 ABS: 0 FINAL ACTION: PASS

01:48 PM

Kathryn Doeschot, Myriam DeLeon, Susan B. Charlifue, and Dr. David Matero, appointees to the Colorado Traumatic Brain Injury Board, described their backgrounds and interest in serving on the Colorado Traumatic Brain Injury Board. Copies of their appointment letters and resumes were distributed to the committee (Attachment C). Senator Mitchell commented on the involvement of members of oversight boards.

(Attachment C can be viewed at State Archives)


BILL:	Conf 09-Colorado Traumatic Brain Injury Board
TIME:	01:56:49 PM
MOVED:	Tochtrop
MOTION:	Refer the appointments of Kathryn Doeschot, Myriam De Leon, Susan Charlifue, and Dr. David Matero to the Colorado Traumatic Brain Injury Board to the full Senate for confirmation. The motion passed on a 7-0 roll call vote, with one member excused.
SECONDED:
		VOTE
	Carroll M.	Yes
	Lundberg	Yes
	Mitchell	Yes
	Morse	Yes
	Newell	Yes
	Schultheis	Excused
	Tochtrop	Yes
	Boyd	Yes

Final YES: 7 NO: 0 EXC: 1 ABS: 0 FINAL ACTION: PASS

01:58 PM -- Sunset Review of the State Board of Nursing

Brian Tobias, Department of Regulatory Agencies (DORA), described the recommendation of DORA contained in the 2008 Sunset Review of the State Board of Nursing (Attachment D). A draft bill containing the recommendations was distributed to the committee (Attachment E). He described the membership and responsibilities of the board. He described the scope of practice for nurses and the licensing process for nurses. Mr. Tobias described the educational requirements for varying levels of nursing. Mr. Tobias described the recommendations contained in the sunset report, which include:

Recommendation 1: continuing the state board and its functions through July 1, 2020;
Recommendation 2: eliminating the requirement that one of the two licensed practical nurses serving on the state board be employed by a rural hospital and instead encouraging the governor, when making appointments to the state board, to strive for geographical, political, urban, and rural balance among the board membership;
Recommendation 3: clarifying that the state board members representing the public cannot currently hold any health care license, and they cannot be employed by or connected with a health care facility or insurer;
Recommendation 4: eliminating the requirement that state board members be confirmed by the Senate;
Recommendation 5: lengthening the terms for the state board members from 3 to 4 years;
Recommendation 6: authorizing the state board to impose civil fines in lieu of other discipline and requiring the state board to adopt rules to define a fining structure;
Recommendation 7: removing the requirement that license applicants submit proof that they are not addicted to drugs or alcohol;
Recommendation 8: modifying provisions regarding grounds for disciplining a licensee, including modifying the grounds for discipline related to excessive use of drugs or alcohol, eliminating the requirement that failure to submit a completed questionnaire must be negligent or willful in order to constitute grounds for discipline, and adding failure to notify the state board of a criminal conviction within 45 days of the conviction as a ground for discipline;
Recommendation 9: consolidating provisions regarding the circumstances in which the state board may deny a license to an applicant who lacks continued competency;
Recommendation 10: requiring a nurse who has been denied a license or had a license revoked to avoid discipline to wait two years before reapplying for a license;
Recommendation 11: repealing obsolete provisions regarding graduate nurse permits and vouchers;
Recommendation 12: repealing the requirement that proceedings relating to complaints against nurses where formal charges are filed are subject to the open records law;
Recommendation 13: clarifying that the state board may conduct a criminal history record check on any person under the state board's regulatory authority;
Recommendation 14: clarifying that professional nurses can perform medical functions delegated by physician assistants;
Recommendation 15: specifying that, in addition to persons seeking to renew a license, applicants for an initial or reinstated license are required to pay a fee to support the Nursing Peer Assistance Program or the Nurse Alternative to Discipline Program;
Recommendation 16: requiring that, as of July 1, 2010, all new applicants for placement on the advance practice registry have national certification;

Recommendation 17: eliminating restrictions on the types of medications that an advanced practice nurse with prescriptive authority can prescribe and changing the requirements for an advanced practice nurse with prescriptive authority to enter into a collaborative agreement with a physician;
Recommendation 18: requiring the board and the Board of Medical Examiners to adopt joint rules governing the collaborative agreements between physicians and advanced practice nurses with prescriptive authority;
Recommendation 19: repealing the "Nursing Shortage Alleviation Act of 2002"; and
Recommendation 20: requiring advanced practices nurses who are engaged in independent practice to obtain professional liability insurance, and allowing the board to adopt rules related to the liability insurance. Failure to maintain liability insurance is added as a grounds for discipline by the board.

02:16 PM

Mr. Tobias responded to questions from Senator Lundberg regarding recommendation 6, stating that fines can be appropriate in certain situations, such as when a nurse fails to renew his or her license and continues to practice. Senator Lundberg questioned whether the level of fines specified in the bill was appropriate for that situation. He responded to questions from Senator Newell regarding recommendation 10. He further responded to Senator Tochtrop regarding recommendation 14, and whether advance practice nurses (APNs) may delegate functions to registered nurses (RNs).

02:32 PM

Mr. Tobias discussed recommendations 17 and 18, stating that the current statutes related to prescriptive authority for APNs are too restrictive and are inconsistent with the full range of health care that an APN may provide. Mr. Tobias explained that these recommendations have been the subject of discussions between the Colorado Nursing Association and the Colorado Medical Society and it is hoped that an agreement on the issue will be reached by the time the bill returns to the Senate Health and Human Services committee for hearing.

02:39 PM

Senator Boyd stated that she would like the committee to wait to consider issues related to recommendations 17 and 18 until the committee considers the sunset bill.

02:44 PM -- Fran Ricker, Colorado Nurses Association, testified that the last sunset review of the Nurse Practice Act occurred 15 years ago. She stated that the association has been working on the sunset review for over a year, and submitted their recommendations to DORA as part of the sunset review. She stated that the association supports collaboration between APNs and physicians, but that the current system of collaborative agreements for prescriptive authority is broken. She testified regarding the association's concerns with recommendations 17 and 18. She stated the association has participated in at least five meetings with the Colorado Medical Society on the issue, and a tentative agreement on the issue has been reached.

02:50 PM -- Tay Kopanos, Colorado Nurses Association, testified that in the past year, the General Assembly removed several barriers to the utilization of APNs, but that barriers still exist. She stated that the collaborative prescribing agreements no longer reflect the practice of APNs and are a barrier to providing care. She stated that the sunset report questioned whether the collaborative agreements were in the best interests of the public. Ms. Kopanos stated that the workgroup formed of members from the Colorado Nurses Association and the Colorado Medical Society has reached a tentative agreement on the issue and described the components of the tentative agreement. In addition to changes to the collaborative agreements, the workgroup has proposed the creation of an ongoing advisory committee on issues related to health care providers.

02:56 PM -- Eliza Johnson, Colorado Chapter of the American College of Nurse Midwives, distributed a fact sheet concerning certified nurse midwives (Attachment F), and testified in support of the DORA sunset report and the recommendations of the workgroup on recommendations 17 and 18.

02:58 PM -- Dr. Ben Vernon, Colorado Medical Society (CMS), testified regarding the working group on recommendations 17 and 18. He stated that the medical society wishes to break down "silos" surround the nursing and medical professions. He described the input given by CMS to DORA during the sunset process, including involvement by physicians in the prescriptive authority of CNAs, and support for collaborative agreements. He stated that the existing structure of the collaborative agreements does not always work for nurses. He stated that the workgroup has proposed a model of prescribing based around articulated agreements. Dr. Vernon stated that if the workgroup fails to reach a final compromise, CMS supports DORA's original recommendations with some amendments. He stated that CMS will seek to add a definition of advanced practice nursing to the Nurse Practice Act, and discussed the reasons why CMS will pursue the amendment.

03:07 PM -- Kari Hersey, Colorado Medical Society, offered to respond to committee questions. Dr. Vernon responded to questions from Senator Newell regarding the status of the compromise reached by the workgroup.

03:09 PM -- Dr. Alex Sluckey, Colorado Medical Society, testified regarding the efforts of the workgroup to reach a compromise regarding recommendations 17 and 18. He spoke to the items the CMS wished to include in the compromise agreement reached by the workgroup. He responded to questions from Senator Newell regarding why the Colorado Nursing Association did not want to address adding a definition of advanced practice nursing to the Nurse Practice Act as part of the workgroup's discussions.

03:15 PM -- Dr. Brian Bacak, Colorado Academy of Family Physicians, testified regarding integrated care for patients and the roles of APNs in providing such care. He recognized the work of the workgroup and DORA in the sunset process. He responded to questions from Senator Newell regarding whether the workgroup agreement would contain a definition of "advanced practice nursing."

03:21 PM -- Cheryl Blankemeier, Colorado Association of Certified Registered Nurse Anesthetists, spoke to the issues related to the definition of "advance practice nursing" and delegated medical authority. She noted that rules related to a definition of advanced practice nursing were promulgated by the Board of Nursing and were reviewed by the Committee on Legal Services to determine whether the rules were outside of the scope of the board's authority. The committee determined that the rules were not. She responded to questions from Senator Newell regarding the difference between "independent nursing function" and "independent medical function." She further responded to questions from Senator Newell regarding the differences in the educational requirements for doctors and nurses. She responded to questions from Senator Mitchell regarding the differences in the scope of practice and activities of certified registered nurse anesthetists and anesthesiologists.

03:35 PM

Senator Morse asked if Ms. Hersey could return to the table to respond to Ms. Blankemeier's testimony regarding delegated medical authority and whether the issue was settled law. Ms. Hersey stated the issue is unclear, and that is why the CMS is seeking an amendment to the Nurse Practice Act that defines advance practice nursing to include delegated medical functions. She stated that the Board of Nursing has promulgated a rule defining advance practice nursing to exclude delegated medical functions. She stated that the rule is ambiguous and makes it unclear whether the practice of APNs includes delegated medical functions.

03:39 PM

Senator Boyd asked that the committee wait to consider issues related to recommendations 17 and 18 and adding a definition of advanced practice nursing to the Nurse Practice Act until the bill returns to the Senate Health and Human Services Committee for a full hearing. Senator Tochtrop stated that the committee should also revisit the board's authority to issue fines when the bill returns for a full hearing.


BILL:	Sunset Review of the State Board of Nursing
TIME:	03:41:18 PM
MOVED:	Boyd
MOTION:	Introduce the draft bill as currently drafted. The motion passed on a 7-0 roll call vote, with one member excused.
SECONDED:
		VOTE
	Carroll M.	Yes
	Lundberg	Yes
	Mitchell	Yes
	Morse	Yes
	Newell	Yes
	Schultheis	Excused
	Tochtrop	Yes
	Boyd	Yes

Final YES: 7 NO: 0 EXC: 1 ABS: 0 FINAL ACTION: PASS

03:41 PM

Senator Tochtrop will be the prime sponsor of the bill and Senator Boyd will be a cosponsor. The committee recessed.