2011 Health Affairs Scholarship

OFFICIAL SECTION OF THE

Gerontological Advanced Practice Nurses Association

2011 Health Affairs Scholarship The 2nd Annual Health Affairs Scholarship for 2011 was awarded to Margo Packheiser from Greensboro, North Carolina. Ms Packheiser was able to attend the American College of Nurse Practitioner’s Summit in Washington, DC, in February 2011, learning more about the legislative process and the issues have an impact on APNs caring for older adults. If you are interested in Health Affairs, consider applying for the 2012 Health Affairs Scholarship. The deadline is November 15, 2011. The recipient will be announced in December 2011. The selected recipient will receive a check for up to $1500 upon submission of a travel estimate documenting anticipated costs relating to the nurse practitioners Summit. By accepting the scholarship you agree to: 



Commit to participate actively on the GAPNA Health Affairs Committee for the next 2 years and to participate in the planning of the Health Affairs Committee activities at the Annual GAPNA Conference. Submit an article on the National Nurse Practitioner Summit for the next issue (early May) of the GAPNA Newsletter after attending the Summit. The article should be no more than 800 words in length and photos are welcome. The deadline for the article is April 2012.

Past HA scholars: Margo Packheiser (2011) and Patty Kang (2010) meet in DC with Health Affairs cochairs Anna Treinkman and Charlotte Kelly. Geriatric Nursing, Volume 32, Number 5



Prior to the Summit, schedule an appointment with your congressional representative and senators to meet Monday during the Summit Hill visits.

GAPNA Annual: Awards of Excellence Susan Mullaney, MS, APRN, GNP-BC Each year GAPNA recognizes those individuals who have gone above and beyond supporting the mission and vision of the organization. This year, there were more than 25 individuals recognized through the nomination process as having demonstrated some or all of the key values of GAPNA. GAPNA is an organization that strives to promote excellence in the care of older adults. This is achieved through a body of individuals working towards improving clinical excellence through education, research, leadership, and community service. For the 2011 Awards, there were 28 nominations for the 6 awards to be presented. The Awards CommitteedSue Mullaney, Barbara Phillips, Virginia Lee Cora, George Smith, and Joan Williamsdreviewed each nomination and after careful review chose the following winners. Chapter Excellence Award goes to the Great Lakes Chapter. The Great Lakes Chapter has 68 members and continues to recruit new members through a variety of activities such as the Oakland University Student Night, Michigan Council of Nurse Practitioners’ Annual Conference and Inaugural nurse practitioners Student Mentorship Night at Madonna University. These programs not only increase awareness of GAPNA and grow membership but also demonstrate excellence in leadership and education as the chapter mentors student and novice NPs. The Great Lakes Chapter enhances the knowledge of all of its members through ongoing educational programs hosting four varied programs throughout 2010 as well as hosting a day-long continuing education event. The chapter members are actively engaged locally on legislative issues and contribute to national research and publications involving the care of older adults. Many Great Lake Chapter members are involved at the national

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level participating on a variety of committees, holding national board positions, and presenting at the national conference. Congratulations to the Great Lakes Chapter! Excellence in Clinical Practice was awarded to Charlene Demers, GNP-BC, CWOCN. Ms. Demers was awarded the Excellence in Clinical Practice for her work with VA patients. She consistently demonstrates the principles of geriatric care, providing evidence-based practice with a specialty in wound care, involving the interdisciplinary team in the care plan, and engaging the patient and family in the development and implementation of an individualized plan of care. Ms. Demers researches and develops clinical practice guidelines, educates others involved in the care of VA patients, and presents her research nationally. Ms. Demers demonstrates excellence in clinical practice and has been recently awarded the 2011 Secretary of Veteran’s Affairs Award for Excellence in Nursing. Congratulations to Charlene Demers! Excellence in Community Service was awarded to Stacey Chapman, MSN, APRN, BC. Ms. Chapman was recognized for her innovation and leadership in developing and implementing a community service project focused on high-risk homebound elders. Ms. Chapman led an initiative that partnered Project Open Hand with United HealthGroup Georgia on a community service project. This project involves Ms. Chapman and her peers preparing and delivering meals to homebound older adults who are at risk for malnutrition. The project then extended to the Georgia Chapter of GAPNA providing meals to more older adults. Thank you to Stacey Chapman for her work! Excellence in Education was awarded to Dr. Cynthia Luther DNS, FNP, GNP. Dr. Luther is a dedicated faculty member of the University of Mississippi Medical Center working as the Program Director for the Geriatric Nurse Practitioner (GNP) program and the project director for the Educational Consortium for Specialized Advance Practice Nursing. As project director, her goal is to establish a statewide consortium offering a collaborative curricula for gerontological and psychiatric/mental health nurse practitioners. Luther coordinated many schools of nursing, the programs, and the faculties to provide the infrastructure of 5 state university nurse practitioner programs for curricula delivery and evaluation. The goals of the project 380

are to eliminate health barriers, assure quality of care, and improve the health care system. Luther led this project, achieving national accreditation through the commission of Collegiate Nursing Education. Congratulations to Dr. Luther! Excellence in Leadership was awarded to Dr. Lisa Byrd, PhD, FNP, GNP. Dr. Byrd is being recognized for her overall leadership skills; she owns and operates a rural clinic in Mississippi and employs and manages nurse practitioners working in nursing home practices. She teaches the GNP program at University of Mississippi Medical Center, is a national speaker on various topics of geriatric care, and has numerous publications to her credit. Dr. Byrd spearheaded the local chapter of GAPNA, is currently the editor of the GAPNA pages in Geriatric Nursing, and participates on the provider unit with the state organization coordinating conferences. She is also an active voice on the Advance Practice Council in Mississippi. In addition, Dr. Byrd is the lead nurse and director for Health Services with the Mississippi Chapter of the Red Cross. Dr. Byrd is an established leader and was recognized by the Mississippi Nurses Association’s Advanced Practice Nurse of the Year in 2008 and the Nurse of the Year in 2010. Congratulations to Dr. Byrd! Excellence in Research was awarded to Dr. Ruth Palen Lopez, PhD, GNP-BC, and Dr. Niloufar Hadidi, PhD, RN, ACNS-BC. Dr. Lopez is engaged in important, provocative research that informs practice and health policy as well as engages students not only to participate in research but to transform practice through the application of her findings. Dr. Lopez devotes her research to examining perhaps the most challenging dilemma facing families and practitioners: whether to guide care toward palliation or to pursue more aggressive treatments for residents with advanced dementia. Dr. Lopez has developed and tested a tool to measure selfefficacy in surrogate decision makers. Dr. Lopez has received support from the John A. Hartford Foundation to study ethnocultural variation in feeding decisions for nursing home residents with advanced dementia. She is currently exploring opportunities to expand this research nationally. Congratulations to Dr. Lopez! Dr. Hadidi has committed her career to establish evidencebased solutions to improve recovery of geriatric patients following a stroke. Dr. Hadidi’s master’s thesis focused on assessment on stroke Geriatric Nursing, Volume 32, Number 5

survivor’s needs, and her PhD research focused on longitudinal patterns of function and depression of geriatric stroke patients. She was selected as a Hartford Geriatric Nursing Education Scholar during her doctoral studies. Dr. Hadidi received a distinguished postdoctoral fellowship to test the feasibility of problem-solving therapy for depressive symptoms of older adults poststroke. Problem-solving therapy has been shown to reduce depressive symptoms in nonstroke populations; however, its feasibility and efficacy with depressed stroke survivors is unknown. Dr. Hadidi will be filling this gap, exploring problem-solving therapy as an alternative to antidepressants. Congratulations to Dr. Haidid!

Update: Advancing Excellence in America’s Nursing Home Campaign GAPNA Long-Term Care Special Interest Group Advancing Excellence in America’s Nursing Homes Campaign began in 2006 as an organization was intended as a way “to help nursing homes achieve excellence in the quality of care and quality of life for the more than 1.5 million residents of America’s nursing homes.”1 From 2006 to 2009, the Advancing Excellence Campaign formed a coalition of 28 organizations. Nurses, caregivers, support staff, medical directors, quality improvement experts, foundations, government agencies, and consumers are represented. Results from the Phase 1 Advancing Excellence Campaign showed that participating nursing homes performed better on the quality improvement measures by the Centers for Medicare and Medicaid Services (CMS) than nursing homes that did not participate. Goal setting was identified as key to the success of nursing homes participating in the campaign. These findings influenced the decision of CMS to reinvest in the Advancing Excellence Campaign and requiring Quality Improvement Organizations to partner with the campaign. Initially, the purpose, mission, and goals of the Advancing Excellence Campaign was only a 2year initiative. Because of the significant contributions to the quality improvement in America’s nursing homes, Phase 2 began on October 22, 2009. The successful campaign has extended into its fifth year. As of July 12, 2011, 7280 nursing homes (which is 46.4% of all nursing homes nationwide) were recruited to make a commitment Geriatric Nursing, Volume 32, Number 5

for quality improvement. There were 4725 charter members and 1882 new participants, 3032 participating consumers, and 1799 participating as nursing home staff. The campaign continues to establish a supporting network for nursing homes called Local Area Networks for Excellence (LANES). The LANES comprise state coalitions of long-term care stakeholders, including nursing home associations, state survey agencies, ombudsman, and consumer advocacy groups. Each state has access to a LANE convener. The LANES enroll nursing homes into the campaign and support the nursing homes in achieving clinical and organizational outcomes by connecting nursing homes to available resources. The Advancing Excellence Campaign Steering Committee chose 8 priority goals to improve quality of care. The goals include: 1) addressing and reducing staff turnover; 2) increasing consistency of caregiver assignments; 3) reducing use of restraints; 4) reducing incidence of pressure ulcers; 5) addressing pain issues; 6) increasing care planning; 7) improving resident and family satisfaction; and 8) improving staff satisfaction. The LANES encourage nursing facilities to identify areas for quality improvement and provide resources to achieve facility goals. The nursing facilities individually select 3 goals to focus on addressing; these quality improvement strategies can be individualized by each facility. The Advancing Excellence website provides online resources with audio recordings, videos, webinars, power point presentations, fact sheets, implementation plans, and tools for tracking progress. The resources were developed by expert consensus and are evidence-based. An Implementation Guide is included for each goal as a road map for success. Recommendations are made for recognition, assessment, and strategies for identifying the causes and contributing factors in areas for quality improvement. Methods and tools for management and monitoring are also available. The Implementation Guide includes a Process Framework to guide a consistent, universal, and systematic approach that is a template for each of the goals. The Advancing Excellence Campaign continues to strive for improvement. The website is user-friendly and provides evidence-based resources. The LANE Projects have grown to move from recruitment to a performance phase. A newsletter is available online to report campaign progress. 381

From the beginning, GAPNA has played an important role in the Advancing Excellence Campaign by showing leadership, commitment, and excellence in nursing. GAPNA members have served as LANE conveners, participating in research studies conducted by the campaign, clearly defining the role and contributions of the advanced practice nurse, recruiting members, and serving on workgroups such as the Clinical Advisory Workgroup that is responsible for the clinical and technical resources. Because of a strong positive influence on the Advancing Excellence Campaign, GAPNA has gained greater recognition by other long-term care organizations, including the Elder Workforce Alliance, the American Medical Directors Association, government agencies, the John A. Hartford Foundation, the American Academy of Nurses, and other professional nursing organizations. The Advancing Excellence Campaign has the unique participation of public/private partnerships and volunteers who have committed to improving quality of care and quality of life for nursing home residents. The LANES are looking for volunteers. Individuals and nursing homes can join the Advancing Excellence Campaign by logging on to the website at http://www.nhq ualitycampaign.org.

March 2010 Report to Congress from the Medicare Payment Advisory Commission (MedPAC). MedPAC reported widespread fraud and abuse potential and stated that there was a need to strengthen accountability in home health certifications.1 This affects home health and hospice agencies, which must meet certain requirements for purposes of certification of a patient’s eligibility. The newly instituted requirements include: 1.

2.

3.

Reference 1.

Advancing Excellence in America’s Nursing Homes. 2011. Available at http://www.nh qualitycampaign.org/

4.

Home Health and Hospice Certification: Changes in the Process, DNR Status, and Concerns about the “Face-to-Face” Encounter Requirement Lisa Byrd, PhD, FNP-BC, GNP-BC, Gerontologist Assistant Professor of Nursing University of Mississippi Medical Center Jackson, MS The Centers for Medicare and Medicaid Services (CMS) established internal processes for practitioners to comply with the new face-to-face encounter requirements for home health and hospice patients, which were mandated by the Affordable Care Act (ACA) effective April 1, 2011. This requirement was proposed based on the

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HOME HEALTH: Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a nonphysician practitioner working with the physician, has seen the patient. The encounter must occur within the 90 days before the start of care, or within the 30 days after the start of care.2 HOSPICE: Section 3132(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient before the patient’s 180thday recertification and at each subsequent recertification. The encounter must occur no more than 30 calendar days before the start of the hospice patient’s third benefit period.2 Documentation for the face-to-face encounter must include the practitioner who saw the patient, the date of the visit, and a description of how the clinical findings of the visit support the homebound patient’s eligibility for home health services.3 Physicians and allowed nonphysician practitioners who attend to the patient in acute or postacute settings (such as hospitals or skilled nursing facilities) may certify the need for home health care based on their face-to-face evaluation in those settings with appropriate documentation. If the acute care/posteacute care physician will be the provider who will follow the patient at home, the physician who will be following the patient may initiate those orders for review and approval by the patient’s community-based physician.3

In consideration for patients who may need home health services, the individual must be “homebound,” and Medicare’s definition is that the patient: 

has a condition that restricts the ability to leave home except with the assistance of another individual or the aid of a supportive Geriatric Nursing, Volume 32, Number 5

device (such as crutches, a cane, a wheelchair or a walker) or leaving their home is medically contraindicated AND 

the illness or injury should be such that the patient is normally unable to leave home and that leaving the home requires a considerable and taxing effort.3

Necessity for the ‘Face-to-Face Encounter’ for Eligibility for Hospice Services MedPAC indicated that there were potential issues of fraud based on the current hospice payment system, which appears to provide an incentive for longer patient stays on such services. It noted that visits and other high-effort services are most frequently provided immediately after the beneficiary comes under hospice care and again at the end-of-life. There is often a stabilization of the person’s illness in middle of the period the patient in under hospice services; but, the Medicare payment rate for hospice services is constant, regardless of the number of visits or services provided. Thus, it is more profitable for the agency to maintain a long hospice stay because, on average, there are fewer visits and services provided to the patient.1 This may be what has led to the potential for abuse of the system, putting the program at risk for inappropriate utilization by some providers. The report indicated that the face-toface requirement would likely benefit providers based on information learned during these evaluations/encounters and better (more appropriately) decide if the patient still requires such services. “Do Not Resuscitate” (DNR) is NOT a Requirement for Hospice Patients According to the Medicare statute, the content of certification for hospice services must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its “normal course.” Contrary to popular belief, the individual is not required to have a DNR order to qualify for this benefit.4 Essentially the law states that an individual who qualifies for hospice services is within the 6-month life expectancy based on the practitioner’s best clinical judgment, although many patients do live beyond this time frame. The hospice benefit is not limited to 6 months; if the individual survives beyond 6 months, the benefit may continue if the person

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continues to meet the qualifying criteria. THE DILEMMA: If a patient is considered to be within the last 6 months of life and follows this clinical expectancy of “dying” but there is no DNR order, the individual is expected to be provided “aggressive” measures to prolong life, thus creating a controversial issue in hospice care. Ethicists agree there are 2 general situations that justify a DNR order: 1.

2.

when cardiopulmonary resuscitation (CPR) is judged to be of no medical benefit (also known as “medical futility”); when the patient with intact decision-making capacity (or when lacking such capacity, someone designated to make decisions for the patient) clearly indicates that he or she does not want cardiopulmonary resuscitation CPR, should the need arise.5

By definition, a patient on hospice services is expected to die and should be offered palliative care-intended to improve quality of life by reducing pain and suffering. However, it may not be appropriate to offer measures designed to extend length of life, such as CPR. Education is the keydallowing the patient and family to understand what palliative care is and what aggressive care is, including the true meaning of CPR (as well as how CPR can affect the patient if he or she survives the resuscitation effort). Concerns There are concerns over patients being placed on hospice services but the individual continuing to be a “full-code” status, that is, CPR will be done if the situation necessitates. Another concern is regarding frequent hospitalizations of hospice patients with the goal of prolonging length of life. In a hospice patient, hospitalizations may be necessary if the goals of care are relieving intractable pain and suffering but not to continue to prolong the dying process. If a patient or family wish to continue to seek aggressive care to increase length of life, then hospice services may not be the most appropriate choice for that particular individual. FACE-TO-FACE ENCOUNTER REQUIREMENT: There were many concerns raised by some agencies regarding the qualifying criteria for home health care services as well as hospice services when the face-to-face requirement was issued in December 2010. Many agencies needed additional time to understand fully the criteria

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and to establish operational protocols necessary to comply with face-to-face encounter requirements. CMS took this into consideration and announced that it would not expect full compliance with the requirements until the second quarter of 2011.2 Because the requirement is currently fully in place, home health agencies, hospices, physicians, and nonphysician practitioners must be familiar with these new requirements to practice appropriately and to avoid any appearance of impropriety as well as added scrutiny from CMS.1 CMS may be contacted for questions concerning the new requirements, and will update information on the following Web site: http://www. cms.gov/center/hha.asp and http://www.cms. gov/center/hospice.asp.

References 1.

2.

3.

4.

5.

Van Regenmorter J, Johnson M. Home health and hospice rules require face-to-face patient visits. Foster Swift Health Care Law Report. 2010. Available at http://www.fosterswift.com/ news-publications-Home-Health-HospiceRules-Require-Face-to-Face-Patient-Visits. html. Cited July 22, 2011. Centers for Medicare & Medicaid Services (CMS). 2011. Available at http://www.cms. gov/center/hha.asp. American College of Physicians (ACP). Home health and hospice eligibility now requires face-to-face encounter. ACP Internist. American College of Physicians; 2011. Available at http://www.acpinternist.org/arch ives/2011/04/tips.htm. Cited July 22, 2011. Medicare Advocacy. Hospice: an important benefit enhanced by the new Medicare law. 2003. Available at http://www.medicarea dvocacy.org/News/Archives/Reform_Act2003 ChangesToHospice.htm. Cited July 23, 2011. Braddock C. Do not resuscitate orders. Ethic of Medicine. 1998. Available at http://depts. washington.edu/bioethx/topics/dnr.html# write. Cited July 22, 2011.

Hospice: An Opinion Regarding Prolonged Coverage & Necessity for ‘DNR’ Status Kim Ratcliff, MSN, ACNP-BC Nurse practitioners (NPs) must realize the state of emergency our health care system is facing. 384

Once we, as a profession, do this, then we must truthfully and wholehearted participate in costcutting measures to ensure that health care will be available and affordable to all Americans for many generations to come. We are finally poised at the forefront of health care for our society. We are providers as well as educators to our patients, families, friends, and other health care providers. What we do with this opportunity will shape the future for our profession for decades to come. One of the many areas we can make a difference is in end-of-life and hospice care. The Obama administration has taken a step toward reducing costs and fixing some of the many problems our health care system poses. One of these major problems lies with certain entities abusing the system and engaging in Medicare fraud, which has perpetuated over the years with home health and hospice. In an attempt to stop what can be considered fraudulent abuse of Medicare funds, The Affordable Care Act laid out guidelines for new hospice regulations. CMS took these guidelines and established the verbiage that is used to direct hospice agencies toward more accountability and better compliance. One of the most important statements made is the definition of a hospice patient being “terminally ill, with a prognosis of 6 months or less if the illness runs its normal course.”1 In this same piece of legislation, Congress gave NPs a groundbreaking role in assessing patients for hospice services and assessing patients for recertification for hospice. Physicians take the NP’s assessments and make the decision regarding qualification for hospice. NPs have been elevated to a significant role in this process. Many patients are placed on hospice after receiving a terminal diagnosis in a hospital setting. They are discharged home on hospice with the belief that if the terminal diagnosis runs its natural course, the patient should die in 6 months or less. However, it must be understood that in many cases, death cannot be predicted that easily. Face-to-face (F2F) visits were created for the recertification of these patients for hospice services. These visits can only be performed by physicians or NPs who are employed by the hospice agency or who is a volunteer. Once again, notice the language used by CMS on recertification: “if the illness runs its normal. . . prognosis of 6 months or less. Therefore, the majority of hospice patients should not require a Face to Face encounter.” Geriatric Nursing, Volume 32, Number 5

An F2F visit means that the practitioner goes to the home and makes an assessment of the patient in this home visit. A head-to-toe assessment along with a review of systems must be included. The practitioner reviews the medications and discusses care with the primary caregiver at this visit. Usually no changes in plan of care are made at this visit. Hospice agencies are required to pay for this visit under the administrative costs of care.2 If changes are needed, these may be discussed at the interdisciplinary team meeting with the hospice team. In some cases, the NP can bill for a visit through Medicare part B if a plan of care change is needed. These F2F visits recertify the patient for 60 additional days of hospice coverage. Once a hospice patient passes into a second 60-day period of coverage, careful consideration is required to determine whether the individual still meets qualifying criteria (i.e., the individual is continuing to decline). Home health may be a less expensive viable option for many patients. The key is to determine whether the patient has a terminal diagnosis in which the individual is declining or is the individual at the end-stage diagnosis of a disease such as chronic obstructive pulmonary disease (COPD) or congestive heart failure (CHF), the symptoms of which can be managed for many years. A signature by the provider (such as the NP) who performs this recertifying assessment is attesting to the fact that a terminal diagnosis is present and death is eminent. The physicians are making their decisions based on our assessments. The author must discuss some pertinent and surely argumentative points. As stated earlier in this article, CMS guidelines state that hospice is for terminally ill patients.2 Once a terminally ill diagnosis is made, all reasonable and available options to treat the disease should have already been done, and further aggressive care is no longer being pursued. It is this author’s strong belief that patients who are placed on hospice should also be designated as “do-not-resuscitate” (DNR) status. Families and our physician colleagues must be educated on these issues before consulting hospice. Education for DNR status must start in the hospital setting. Explanation of the terminal diagnosis, its course to imminent death, and palliative care must start at hospital. Hospice agencies should educate that “do not resuscitate” does not mean “do not treat.” There must also be an Geriatric Nursing, Volume 32, Number 5

emphasis that hospice services are for allowing a patient to die at home with dignity and be as pain- and anxiety-free as possible. Emergency room (ER) visits for hospice patients should rarely occur. One visit to the ER usually costs more than 2 months of hospice care. It should also be noted that the hospice agency is required to discharge the patient from hospice services for the ER visit. When the patient is discharged from the hospital (or the ER), the patient might then be readmitted to hospice services, which will require another F2F assessment. An example of a reasonable ER visit would be a fall that resulted in a fracture or trauma. Potentially inappropriate ER visits include shortness of breath in an end-stage COPD patient or chest pain in an end-stage CHF patient. Education is the key to reducing ER visits in the terminally ill patients. In conclusion, the opinions here are those of the author and are intended to create discussion regarding end-of-life care and hospice. In Mississippi, where this author practices in a high acuity long-term care facility, the most frequently presented inquiries with ER nurses whose first and second questions are “what is the patient’s code status?” and, when DNR is stated, “why are you sending his patient here?” Commonly occurring are multiple hospice patients who are “fullcode” status who visit the ER. These patients have to be discharged from hospice and likely readmitted on return to the long-term care setting. Trends in the average life expectancy are increasing. The baby boomers are hitting Medicare by the thousands daily. Education is the key to changing public perception about end-of-life issues. NPs are the key to educating the public.

References 1. 2.

Affordable Care Act: Sections 3132,1814(a) (7), 418.22(b)(3). Medicare Payment Advisory Commission. Report to the Congress: medicare payment policy, Chapter 6. 2009; 365e71.

Introducing the GAPNA Online Library: www.prolibraries.com/gapna We are pleased to announce a new service to our members: the GAPNA Online Library! In one spot, you’ll be able access education right

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at your fingertips. The Online Library gives you the opportunity to earn continuing nursing education (CNE) contact hours and access education sessions from the GAPNA Conference. Did you attend our 2011 conference? All attendees receive FREE access to the educational content! Download the audio recordings of the sessions you missed and listen to them at your convenience, at no additional charge (CNE processing fees apply). Missed the 2011 conference? You can purchase individual sessions, preconference sessions, or the entire conference (CNE fees included). Visit www.prolibraries.com/gapna to see the wonderful content available. Visit the Online Library Now! Stop by the Online Library today to access a FREE session,

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listen to the “Presidential Minute,” and become familiar with this new member benefit. We are currently offering a free CNE session, “Advanced Pathophysiology of the Lower Urinary Tract,” presented at the Society of Urological Nurses and Associates (SUNA) 2010 Annual Conference. Visit the Online Library to earn this free CNE! If you are a GAPNA member, your account is already set up for you! Just log in to the Online Library with your GAPNA primary e-mail address and your password. If you are not a GAPNA member, simply create an account (it’s free!). 0197-4572/$ - see front matter Ó 2011 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2011.07.009

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