Hawaii’s Act 169: Empowering Nurses and Expanding Primary Care Access for Consumers

 At the Lanai Community Health Center, a community clinic on the rural Hawaiian island of Lanai, nurses and patients spend a lot of time waiting around for physicians. The nurses who provide most of the care need licensed physicians to write prescriptions, sign off on disability claims and check patients into the hospital, among other things. But it’s not just the paperwork; it’s the clinic’s capacity to provide one-stop primary care and serve as the “medical home” for this tiny community with many immigrants, according to Anne Leake, PhD, APRN-Rx, FNP.  Leake is a nurse practitioner at the clinic when she’s not teaching and researching at the University of Hawaii, Honolulu School of Nursing. “As long as it takes to earn a patient’s trust, it makes no sense that the patient has to go through a second exam, interview and paperwork, with a physician they’ve never met, just to get the treatment we already know they need,” says Leake. “It’s often a real deterrent to our patients getting the care they need.”

But all of this is has begun to change. On July 2, 2009, Hawaii Governor Linda Lingle signed into law Act 169, giving Advanced Practice Registered Nurses (APRNs) in the Aloha State a wider “scope of practice” that allows them to provide many services typically performed by primary care physicians – without signoff from a licensed physician. APRNs are registered nurses who have met advanced educational and clinical practice requirements, at the Master’s level at a minimum, and are certified to practice in areas such as primary care, midwifery, psychiatry and anesthesia.

Once fully implemented, Act 169 will result in four important changes that will give more Hawaii citizens greater access to primary and preventative health care. (1) 

Effective upon the Governor’s signature, Hawaii’s APRNs were granted global signature authority, meaning they can now sign and certify most forms related to care within their particular specialty.  For example, nurse practitioners can now certify someone healthy enough to undergo surgery following a physical exam, or ill enough to qualify for disability insurance. 

Six months after the law was signed, the state clarified its definition of an APRN and also expanded it to allow APRNs who were registered in other states to become licensed and work more easily in Hawaii. 

The law also will allow health insurance plans to recognize APRNs as primary care providers. Although the precise implementation of this provision is still being determined, it means that just as insurers contract with physicians to provide primary care and refer patients to specialists, now APRNs are authorized to play that same role. 

Finally, Act 169 includes a key provision concerning APRNs’ prescriptive authority, and the state’s Board of Nursing has been finalizing details about how this will work in practice.  While APRN’s in Hawaii have been prescribing non-controlled substances (e.g. antibiotics, blood pressure medications, diabetes treatments) since 1997, the new law will expand their authority to prescribe controlled substances (e.g. powerful pain medications and additional psychiatric drugs) without a physician’s signature. APRNs will need to apply to the Board of Nursing for the expanded authority, renew it each year and meet the following general requirements: has achieved 30 credits of pharmacology training within the last three years; prescribes within his or her own area of expertise; has established a collaborative relationship with a licensed physician. (2) 

Hawaii’s Act 169 contains multiple components and overlaps in many areas where existing state and federal laws already apply. Several government agencies as well as health care organizations and industries will be working out the specifics of its implementation for some time to come.  Meanwhile, many of its benefits are already in effect and easing consumers’ access to primary care in the state.

This landmark legislation was an idea whose time had come.  The APRN bill not only solved a critical community need for medical services, it provided it at no cost.  So while the legislation faced opposition by traditional longstanding opponents, this time many community stakeholders rallied behind the bill, enabling it to move quickly from the legislature to the Governor’s desk.  Legislation was introduced by Representative Marilyn Lee, herself a registered nurse, and Senator Roslyn Baker in March 2009 and was signed by the Governor that July.

For lawmakers, a leading motivation to pass the law was recognition of a severe shortage of physicians in Hawaii.  According to the Hawaii Physician Workforce Assessment conducted by the University of Hawaii at Manoa’s John A. Burns School of Medicine, Hawaii in 2010 is at least 500 doctors below national averages, given its population, and the deficit may double or triple in the next decade.  This means the state has roughly 20 percent fewer doctors than it should when compared to physician-to-population ratios nationally. There are only about 2,900 doctors practicing in Hawaii, and not all of them work full time.  And like the nurse workforce – or any workforce in any state, for that matter – Hawaii’s physician population is aging: 43 percent will be 65 or older by 2020 and an estimated 1,100 of its 2,900 practicing physicians will be retiring over the next decade. (3) At the same time, as result of the same baby boom that is leading its physicians to retire, Hawaii’s overall population is aging.  According to the state’s Executive Office on Aging, in 2020 there will be more than 351,000 Hawaii residents over age 60, and another 33,000 over age 85.  Amounting to roughly one quarter of the state’s entire population in the next decade, these older Hawaii residents will need more care than their younger counterparts, and much of it, specialized.(4)

AARP Hawaii, which advocates for these older residents, provided a vital consumer voice in advancing Act 169.  The AARP State Office, under the leadership of its State Director, Barbara Kim Stanton, strongly advocated expanding access.  Although AARP’s members are aged 50 and up, they support greater access to healthcare benefits for all of the state’s health care consumers, including, for example, the young families served by the Lanai Community Clinic.

“AARP members strongly support this legislation because it increases access and removes barriers to health care, particularly in rural and underserved parts of our state,” says Stanton.  AARP is pleased with the new law because it recognizes nurses as full participants in providing health care, and allows them to provide health care services to communities that desperately need them.  Wielding data from its membership surveys showing how limited access to care was, AARP Hawaii helped make the case that health services would worsen dramatically if nurses were not empowered to provide a full scope of primary care for the state’s residents.

Of course, before lawmakers at any level authorize new laws or programs, they need reliable evidence to justify the funding.  Joining AARP in providing such data was the Hawaii Center for Nursing.  The Center was created by the state legislature for exactly this purpose: to generate reliable information, including basic data and best practices, to help the state target funding and programs that will ensure a well trained, well populated nurse work force for the citizens of Hawaii.

In 2006, for example, the Center provided key data that persuaded the legislature to allocate funds for 17 new nurse faculty positions in the university system; it was one of the early reports the Center delivered that established its credibility with lawmakers.  It was also the beginning of a positive and productive relationship, according to Barbara Mathews, MS, APRN, NEA-BC, the Center’s founding executive director, who now teaches at the University of Hawaii, Manoa School of Nursing. “Many legislators told us our data was invaluable in helping them craft bills,” she says. “By the time Act 169 was under consideration, we had the credibility and relationships with our legislators in Honolulu to help make the case for it” when the legislation was in play.

Significantly, the Center also served as the hub for a coalition of stakeholders, giving the bill its momentum, a coalition that had its roots in a statewide team that was working with the Center to Champion Nursing in America (CCNA).  An initiative of AARP, the AARP Foundation and the Robert Wood Johnson Foundation, CCNA works to increase the nation’s capacity to educate and retain nurses who are prepared and empowered to positively impact health care access, quality, and costs for the benefit of consumers.  Hawaii assembled a team that included representatives from community health clinics, health plans, the state Board of Nursing, nursing schools, health care employers and five members of the state legislature. Participating in a CCNA summit, creating working groups and task forces all helped to strengthen the partnerships among team members and focus everyone involved on the goals for Hawaii. “I go back to this partnership history,” says Mathews, “because it meant we could build upon our collaborative relationships.”

Hawaii now joins 16 states and the District of Columbia in allowing its APRNs to practice primary care with little or no physician oversight. (5) This trend is good news for all health care consumers since estimates of the future primary care workforce project a shortage of 35,000 to 44,000 adult primary care providers nationwide by 2025. (6) Additionally, health care reform is likely to mean another 30 million or more Americans will be seeking this kind of care. 

Anne Leake sees great benefits for her Lanai clinic.  By reducing barriers to APRN practice, Hawaii’s new law is not only helping patients but saving money by minimizing redundancies in tests and treatment.  It is also reducing the need to evacuate patients to other facilities for care APRNs like Leake can now provide.  “Our patients are always going to need physicians,” says Leake, “but now nurses and doctors can work together, and more efficiently, for the benefit of all our patients.”

1) http://hawaii.gov/dcca/pvl/news-releases/nursing_announcements/act-169_slh_2009.pdf
2) All of the proposed rules for implementing Act 169, including prescriptive authority, are at http://hawaii.gov/dcca/pvl/har/pvl/ProposedHAR16-89_Nurses.pdf
3) http://www.hawaii.edu/news/article.php?aId=3694
4) http://hawaii.gov/health/eoa/Docs/Plan.pdf
5) http://championnursing.org/sites/default/files/aprnmap.branded.10.28.10_ref.10.1.10.pdf
6) Bodenheimer, Thomas and Hoangmai Pham. “Primary Care: Current Problems and Proposed Solutions.” Health Affairs 29 (2010): 799-805.