Ask a Professor: The NP Practice Environment in Kentucky
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“I think, without question, the NP role will continue to expand. It would be much easier if we didn’t have some of these restrictions on our practice, but we’ve always found a way to take care of patients, and we will continue to do that. We will keep moving forward.”
Dr. Margaret Zoellers, Associate Professor, Rural Health FNP Program Coordinator at Eastern Kentucky University
As the nation recovers from the Covid-19 pandemic, attention is turning to another looming crisis. The aging Baby Boomer generation is putting immense strain on healthcare resources around the country. There are not enough primary care physicians to meet the health needs of the nation. The Association of American Medical Colleges (AAMC) projects shortages of up to 48,000 primary care physicians by 2034.
In some states, such as Kentucky, the primary care crunch is already acutely felt. According to the Kaiser Family Foundation (KFF), in 2022 Kentucky had 191 Health Professional Shortage Areas (HPSAs) that were home to a collective 1.46 million people, which amounted to roughly a third of the state’s entire population.
Medical schools aren’t graduating enough primary care physicians fast enough to match the growing demand for their services. But they also shouldn’t have to: Kentucky’s nurse practitioners (NPs) are a valuable resource in fighting back against the primary care crunch and increasing healthcare access to those who need it.
If utilized to their full potential, Kentucky NPs could have a major impact on the state’s overall health.
Meet the Experts
Margaret Zoellers, DNP, APRN, FNP-BC
Dr. Margaret Zoellers previously served as Associate Professor and Rural Health Family Nurse Practitioner (FNP) program coordinator at Eastern Kentucky University’s School of Nursing. She earned both her MSN and DNP from Eastern Kentucky University.
Dr. Zoellers has more than 24 years of advanced nursing practice experience, primarily in family practice but also in women’s health, internal medicine, urgent care, and university student health. Prior to earning her MSN, she spent five years in registered nursing practice, with experience in medical/surgical, home health, and emergency care.
Dr. Zoellers was interviewed for this feature in January 2022.
Angela Wood, DNP, APRN, FNP-C, PPCNP-BC
Dr. Angela Wood currently serves as the clinical faculty and FNP program coordinator at Eastern Kentucky University School of Nursing. She earned both her MSN and DNP from Eastern Kentucky University.
Dr. Wood is a board-certified family nurse practitioner and a board-certified pediatric nurse practitioner. Her research and academic interests include childhood obesity. In 2019, Dr. Wood received the Blackboard World Catalyst Award for Teaching and Learning.
Dr. Wood was interviewed for an update to this feature in February 2024.
The Power and Potential of NPs in Kentucky
Over 50 years of research has shown that NPs can and do improve patient outcomes across a broad range of healthcare services. They’re highly educated and expertly trained and widely trusted: nursing has been the most trusted profession in America for 19 consecutive years. That trust and expertise and a holistic approach to care make NPs the ideal choice for educating and treating patients with chronic conditions.
“NPs are extremely important members of the healthcare team in Kentucky,” Dr. Zoellers says. “The state has a very high rate of chronic disease, and when you think about chronic diseases like heart disease, hypertension, and diabetes, primary and secondary prevention is just critical. And that’s what NPs emphasize. But there also must be access to primary care, and NPs in Kentucky have really filled a big gap in that area.”
NPs are more likely than their physician colleagues to work in rural and underserved areas, particularly in Kentucky. Eastern Kentucky University’s FNP program, where Dr. Zoellers previously served as Assistant Professor and program coordinator, explicitly emphasizes the unique challenges of providing care in rural and underserved areas.
“The vast majority of our students come to EKU, complete their advanced degree, and then return to their home community,” Dr. Zoellers says. “They don’t intend to practice anywhere else. They have a strong desire to make a difference in their home community. Since many of our students are also from rural or underserved communities, it follows that many of our graduates establish a practice with underserved populations.”
In 2018, NPs represented one in four primary care providers in rural practices, and the number is even higher in states with full practice authority laws. Kentucky, unfortunately, is not one of those states.
The Burdens of Reduced Practice for NPs in Kentucky
Kentucky is classified by the American Association of Nurse Practitioners (AANP) as a reduced practice state, meaning that the state’s laws reduce the ability of NPs to engage in at least one element of their practice.
In Kentucky, that reduction manifests primarily in the requirement of collaborative agreements. The Kentucky Board of Nursing licenses Kentucky NPs and can practice independently. Still, they must have collaborative agreements in place with a supervising physician to prescribe medications: a Collaborative Agreement Prescriptive Authority for Controlled Substances (CAPA-CS) and a Collaborative Agreement Prescriptive Authority for Non-Scheduled Drugs (CAPA-NS). Each comes with its own requirements and its own burdens.
Kentucky isn’t as restrictive as some other states are. Physicians in Kentucky can collaborate with any number of NPs at one time. There is no distance requirement, no mandatory chart review, and no direct supervision necessary. Nothing in Kentucky’s regulations explicitly prevents an NP from opening an independent practice.
That said, requiring each NP to pair themselves to a physician for prescriptive authority drastically undermines the force-multiplying power that NPs can provide. And the current regulations create significant barriers that disincentivize independent practice by NPs and discourage NPs from moving to the rural and underserved areas where they’re needed most.
As the sole primary care provider in many rural areas, NPs must be able to prescribe controlled medications. Without the ability to independently order antibiotics or injectable vaccines, for example, an NP’s capacity to establish independent practice and treat and care for patients is greatly diminished.
NPs who want to practice in these rural and underserved areas must find a physician willing to enter into a collaborative agreement with them, and typically incur a financial burden from entering into that agreement. If at any point the physician retires, dies, or simply decides to no longer participate in that agreement, then the NP needs to shut down their practice until a replacement is found. Even a minor disruption in the continuum of care can have major consequences for patients who look to NPs as their sole source of health services.
“Removing these barriers just makes sense,” Dr. Zoellers says. “It would allow NPs to practice to the full scope of their education and training in the areas they’re needed most. Right now, we’re not allowed to do that in Kentucky. But the bigger issue is how does that impact our patients and access to care?”
The Future for Kentucky’s NPs
Like many other states, Kentucky issued an executive order at the beginning of the Covid-19 pandemic to waive certain practice requirements for NPs. Specifically, Kentucky eliminated the one-year practice requirement for a CAPA-CS.
At the beginning of 2022, during the height of the Omicron variant wave, that executive order was abruptly rescinded. NPs like Dr. Zoellers were left to wonder if NPs are competent enough to practice without added restrictions during an emergency, why would that not always be the case? And isn’t the primary care shortage—both in Kentucky and across the country—its own looming emergency?
“Our professional organization has supported legislation for the last several years regarding the CAPA-CS in trying to make it less restrictive,” Dr. Zoellers says. “I’ve been an NP since 1997, and I’ve been involved in every round of this legislation, talking to our legislators, advocating for improved access to care. I think it will continue to be a difficult fight.”
For new and aspiring NPs who want to make a difference, Dr. Zoellers advocates for joining professional organizations such as the Kentucky Association of Nurse Practitioners and Nurse Midwives (KANPNM). In addition to acting as a collective voice for the state’s NPs, KANPNM also hosts a Legislative Day in February, where NPs go to Frankfort to meet with their legislators. Dr. Zoellers emphasizes the importance of educating those legislators on who NPs are, their scope of practice, and the thousands of Kentuckians they care for in rural and underserved areas.
“It’s really just a matter of making sure that the correct information gets out there,” Dr. Zoellers says. “Everything points to a continued strong need for NPs in Kentucky.”
Progress may be slow, but it’s coming. Several states have, in recent years, passed progressive legislation that removes anachronistic barriers on NP practice. During the pandemic, even more states got firsthand experiences with what full practice authority for NPs looks like. Increasingly, utilizing NPs to the full extent of their education and training won’t be seen as a choice but a necessity, and patients everywhere will benefit.
“I think, without question, the NP role will continue to expand,” Dr. Zoellers says. “It would be much easier if we didn’t have some of these restrictions on our practice, but we’ve always found a way to take care of patients, and we will continue to do that. We will keep moving forward.”
Update 2024: Taking Steps Towards Full Practice Authority
Many of the problems of 2022 persist. As of early 2024, Kentucky had 255 HPSAs with a total population of over 2.12 million, accounting for nearly half the total population. Meanwhile, Kentucky remains a reduced practice state while more and more other states have transitioned to full practice authority. However, Kentucky has taken some legislative steps in the right direction, particularly concerning the prescription of controlled substances.
“After four years of practice, NPs may choose to dissolve their CAPA-CS agreement,” Dr. Wood says. “But there are some requirements for that agreement to be dissolved.”
To dissolve the CAPA-CS, NPs with four years of experience as prescribing NPs must submit a request for exemption to the Kentucky Board of Nursing (BON). The BON must have the NP’s DEA registration and Kasper account (Kasper is a prescription monitoring system), along with the original CAPA-CS on file. Finally, the NP must pay a fee and their license must be determined to be in good standing.
There are additional requirements for newer NPs, specifically those who did not have a CAPA-CS before June 29, 2023. Before applying for an exemption, they must meet with the licensed physician with whom they originally entered into the CAPA-CS to review their Kasper reporting and prescribing practices related to controlled substances. Those meetings must occur at prescribed intervals for four years, either virtually or in person, and be recorded and documented—the BON may request documentation from the NP or collaborating physician at any time.
“It’s a compromise,” Dr. Wood says. “We were ultimately looking to eliminate the CAPA-CS altogether. But for NPs who’ve been in practice for a long time, this is still a big barrier that’s been removed. For new NPs, there’s some oversight where they must demonstrate safe prescribing practices. It’s a baby step in the right direction.”
The right direction is full practice authority, with no restrictions in prescribing. Dr. Wood points out that it wasn’t just NPs but also their patients who noticed when the Covid-19 waiver on the CAPA-CS requirement was rescinded. Suddenly, their NP provider could no longer provide them with all the same services as before, leading to gaps in care. In areas where there’s already a shortage of primary care providers, restricting the ability of the few there is exacerbating the healthcare access crisis.
“I would say we’re still in a state of emergency, but one unrelated to the pandemic,” Dr. Wood says. “The continued aging population and the shortage of primary care providers, especially in rural and underserved areas, is an emergency in and of itself.”
Kentucky, like much of the nation, has high rates of chronic disease, particularly hypertension, hyperlipidemia, type II diabetes, and COPD. That creates a large demand for chronic disease management, which NPs are well-positioned to perform. NPs can also address the problem upstream: their holistic approach to care focuses on disease prevention and health promotion.
Kentucky’s NPs continue to advocate for more progressive legislation that empowers them to practice to the full extent of their training and education. On February 15, 2024, the state’s NPs had their annual Legislative Day at the Capitol.
“We need to know who our legislators are, and we need to let them get to know us—explaining who NPs are, what we do, and what healthcare issues we see our patients facing,” Dr. Wood says. “There are some things we can do individually, but there is a bigger voice with more numbers.”
Awareness of the NP role continues to grow, as does its prominence. In 2024, US News & World Report ranked nurse practitioner as the best STEM job, the best healthcare job, and the best job overall. If Kentucky can continue to take steps towards full practice authority, then the state’s NPs, and their patients, can be very hopeful for the future.
“NPs are in a unique position to help fill the healthcare gaps in the United States and here in Kentucky,” Dr. Wood says. “I think the future looks bright for NPs.”
Matt Zbrog
WriterMatt Zbrog is a writer and researcher from Southern California, and he believes nurse practitioners (NP) are an indispensable component of America’s current and future healthcare workforce. Since 2018, he’s written extensively about the work and advocacy of NPs, with a particular focus on the rapid growth of specialization programs, residencies, fellowships, and professional organizations. As part of an ongoing series on state practice authority, he’s worked with NP leaders, educators, and advocates from across the country to elevate policy discussions that empower NPs. His articles have featured interviews with the leadership of the American Association of Nurse Practitioners (AANP), the National Association of Pediatric Nurse Practitioners (NAPNAP), and many other professional nursing associations.