Advanced Practice Registered Nurses Achieve Full Practice Authority in Illinois: Now What?

With the passage of HB 313 in 2017, advanced practice registered nurses (APRN) now have full practice authority, free from mandatory oversight by a collaborating physician, in Illinois. Before they avail themselves of this new legal authority, APRNs should make sure they understand the details in HB 313 and pending regulations to implement the legislation, as well as the practical effects that full practice authority will have on their careers and practices.

In late 2017, Illinois joined a growing number of states in granting advanced practice registered nurses (APRN) full practice authority with the passage of HB 313. Most of the key provisions of the legislation took effect on January 1, 2018, and in the year thereafter, the Illinois Department of Financial and Professional Regulation (IDFPR) proposed regulations to implement the legislative reforms.

Given that HB 313 has already taken effect yet the implementing regulations remain in draft status, APRNs and other stakeholders may wonder what APRNs can and cannot do for the time being. In this post, we take a look back at the changes that HB 313 made, review IDFPR’s proposed regulations, and consider the practical impacts that these developments may have both in the short term and in the long term for interested parties.

HB 313: Full Practice Authority Becomes a Reality

HB 313 made several revisions to the Illinois Nurse Practice Act, including extending the comprehensive nurse regulatory scheme from its scheduled expiration date of January 1, 2018 through January 1, 2028. For APRNs, chief among HB 313’s modifications is its allowance for full practice authority. This refers to the authority of APRNs – a category of practitioners that includes nurse practitioners (NP), nurse midwives (NM), and clinical nurse specialists (CNS) – to engage in professional practice without a written collaborative agreement with a physician. In the words of the legislation, “full practice authority” specifically means that an APRN:

• Is fully accountable to patients for the quality of advanced nursing care rendered;
• Is fully accountable for recognizing limits of knowledge and experience and for planning for the management of situations beyond the APRN’s expertise; the full practice authority for APRNs includes accepting referrals from, consulting with, collaborating with, or referring to other healthcare professionals as warranted by the needs of the patient; and
• Possesses the authority to prescribe medications, including Schedule II through V controlled substances.[1]

To qualify for full practice authority, an APRN must complete at least 4,000 hours of clinical experience in the APRN’s area of certification, after having first obtained national certification. Additionally, the APRN must complete at least 250 hours of continuing education or training in the APRN’s area of certification.

Prior to HB 313, all APRNs (except for those working in hospitals and ambulatory surgical treatment centers) were required to maintain a written collaborative agreement with a physician in order to engage in the full APRN scope of practice. The collaborative practice agreement describes the relationship between the APRN and collaborating physician and those categories of care, treatment, or procedures to be provided by the APRN.[2] For APRNs to whom a collaborating physician has delegated prescriptive authority, the collaborative agreement also includes the parameters within which the APRN is authorized to prescribe, administer, and dispense over-the-counter medications, legend drugs, and controlled substances.[3]

Thus, HB 313 significantly reduces physician oversight with respect to APRNs. However, as we discuss further below, APRNs and other stakeholders should be aware that even with HB 313’s full practice authority reforms, some notable limitations on APRN remain in place.  

IDFPR’s Proposed Regulations

The full practice authority provisions of HB 313 took effect on January 1, 2018, but the legislation contemplated that IDFPR would need to promulgate new implementing regulations. On October 12, 2018, IDFPR released those regulations in proposed draft form.

As proposed, IDFPR’s regulations largely mirror the provisions of HB 313, incorporating the statutory changes into the agency’s existing APRN regulations. Most notably, the regulations clarify the process that APRNs must follow to obtain the approval to exercise full practice authority. This process will require an ARRN already certified as an NP, NM, or CNS to pay a $125 fee and submit a form to IDFPR that documents the following:

• The APRN’s Illinois APRN license number and registered professional nurse license number (both of which must be current, active, and unrestricted);
• A notarized attestation, signed by the APRN, of completion of at least 250 hours of continuing education or training in the APRN’s area of certification. The draft regulations clarify that the continuing education or training can be from an approved continuing education sponsor, a graduate education program at a university or college, a professional association that provides continuing education programs required for certification or recertification, or other educational opportunities that comply with IDFPR regulations; and
• A notarized attestation of completion of at least 4,000 hours of clinical experience in the APRN’s area of certification after first attaining national certification.

Once an APRN has received full practice authority, the APRN will be able to maintain the full practice authority on an ongoing basis, subject to paying a $40 license renewal fee.

What’s Next?

When IDFPR unveiled the proposed regulations on October 12, 2018, it requested public comments over a subsequent 45-day period. That comment period is now closed, and the next step will be for IDFPR to issue a second notice of the regulations, which will include any changes to the regulations based on the comments IDFPR received.

Before the regulations are finalized, the Joint Committee on Administrative Rules (JCAR), a body comprised of legislators from both houses of the Illinois General Assembly, must review them. If JCAR does not object to the regulations, IDFPR will have a year from the date of initial publication to issue the regulations in final form. This means that the final regulations would be expected sometime before October 12, 2019.

Understanding the Implications of Full Practice Authority

As IDFPR’s regulations continue through the rulemaking process, APRNs, their collaborating physicians, and other interested parties should consider how full practice authority will affect their practices and prepare accordingly. We offer below our thoughts regarding some of the questions APRNs and other stakeholders may have in light of HB 313’s reforms.

May an APRN who meets all the clinical training and continuing education hours under HB 313 go ahead and exercise full practice authority?

No. HB 313 makes clear that an APRN must provide a “notarized attestation” that the APRN meets the qualifications for full practice authority. The purpose of the IDFPR regulations is to clarify the process for APRNs to submit the notarized attestation. Until that process has been implemented with the release of IDFPR’s final regulations, APRNs should not exercise full practice authority, even if they have the necessary qualifications.

Are there any limitations to the scope of practice of an APRN with full practice authority, and are there are any circumstances where an APRN with full practice authority should still consult or collaborate with a physician?

Yes. HB 313 limits an APRN with full practice authority to using only local anesthetics (meaning that administration of general anesthesia is not allowed) and prohibits an APRN with full practice authority from performing operative surgery. The legislation also provides that where a law or regulation otherwise specifically requires that a healthcare service be rendered by a physician, an APRN with full practice authority is not authorized to provide the service. Thus, for example, APRNs with full practice authority may not perform abortions, which Illinois law requires to be performed by a physician.

Notably, HB 313 includes practice restrictions and physician oversight with respect to an APRN’s prescribing of benzodiazepines or Schedule II narcotic drugs, such as opioids. To prescribe these substances, an APRN with full practice authority must maintain a “consultation relationship” with a physician, with whom the APRN must discuss the condition of any patients for whom a benzodiazepine or opioid is prescribed at least monthly. The consultation relationship must be recorded on the Illinois Prescription Monitoring Program website (though it need not be filed with IDFPR).  

Practically speaking, APRNs with full practice authority may still find it helpful to consult and seek the opinions of those physicians with whom they have developed longstanding collaborative relationships. Nothing in HB 313 precludes those relationships from continuing on an informal basis. Indeed, as noted above, “full practice authority” is defined to include “accepting referrals from, consulting with, collaborating with, or referring to other healthcare professionals as warranted by the needs of the patient.”

Must APRNs who do not obtain full practice authority continue to have a collaborative agreement with a physician and comply with the existing rules on delegation of prescriptive authority?

Yes. Those APRNs who do not qualify for full practice authority must maintain a written collaborative agreement with a physician that complies with the Nurse Practice Act and IDFPR regulations, including the rules on delegation of prescriptive authority.

How will full practice authority affect APRN’s controlled substances licensure?

Both before and after HB 313, APRNs could, and still can, obtain a state controlled substances license from IDFPR and a federal controlled substances registration from the U.S. Drug Enforcement Agency (DEA). Now that APRNs with full practice authority can independently prescribe controlled substances, IDFPR will no longer require receipt of a notice of delegated prescriptive authority from a collaborating physician.

How will full practice authority affect APRNs in their day-to-day practices and patient care activities?

The impact of full practice authority will largely depend on an APRN’s specialty and the nature of their practice. From a clinical standpoint, full practice authority will not necessarily change how APRNs render care. It will, however, afford APRNs greater independence and judgment in rendering care. This will make it more important than ever for APRNs to understand and appreciate the limitations of their knowledge, training, and experience and to continue to consult physicians and other providers as appropriate. To these ends, APRNs with full practice authority may find it helpful to complete additional continuing education in those areas where they are less experienced. Indeed, contemplating the need for further continuing education as more APRNs transition toward full practice authority, HB 313 increased the number of continuing education hours that APRNs must complete each two-year renewal cycle, from 50 hours to 80 hours.

Are APRNs with full practice authority at greater risk of malpractice liability?

With an expanded role, APRNs with full practice authority may be at increased exposure to claims of malpractice. Therefore, APRNs with full practice authority should review their insurance policies and make sure they adequately protect against the risks that the APRN may take on in exercising full practice authority. In some cases, APRNs with full practice authority may receive malpractice coverage from their employer but may find it appropriate to acquire additional coverage through an individual malpractice insurance policy.

What kinds of new business opportunities does full practice authority present for APRNs?

By freeing APRNs to engage in independent practice, full practice authority potentially opens up a wide range of opportunities for APRNs. Some APRNs may opt to develop private practices. These APRNs will need to work through all the issues that arise in operating a physician practice, such as managing support staff, following a compliance plan, and ensuring coverage of services by third-party payors. Other APRNs may opt to work as employees or contractors of clinics, hospitals, and other organizations. To the extent they take on greater responsibilities with full practice authority, these APRNs may find it appropriate to seek a pay raise or otherwise renegotiate the terms of their contracts.

Contact One of Jackson LLP’s Experienced Healthcare Attorneys to Assist You in Your Transition to Full Practice Authority

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[1] 225 ILCS 65/50-10
[2] See 225 ILCS 65/65-35(b).
[3] See 225 ILCS 65/65-40.