Background

The Nurse Support Program II (NSP II) is funded by the Health Services Cost Review Commission (HSCRC) and administered by Maryland Higher Education Commission (MHEC). The goal of the Nurse Support Program is to increase the number of nurses in Maryland. NSP I supports hospital centered initiatives while NSP II focuses on expanding the capacity to educate nurses through increasing faculty and strengthening nursing education programs at Maryland institutions.

Over the last two years, several nursing workforce reports have been released. The Maryland Board of Nursing (MBON) Maryland Nursing Workforce Shortage, the Maryland Nursing Workforce Center (MNWC) Maryland RN Workforce Survey and the MHA have provided insights. Please see more at the MHA Modified Health Care Workforce Report. You can find the full length report here: MHA 2022 State of Maryland's Health Care Workforce Report. Additionally, the GlobalData: Maryland Nurse Workforce Projections 2021-2035 and GlobalData: Maryland Nursing Workforce Study. We encourage nursing programs seeking grant funding through NSP II to utilize the information in these reports.

The Health Services Cost Review Commission (HSCRC) initiated nurse education support funding (formerly titled the Nurse Education Support Program or NESP) in 1986 through the collaborative efforts of hospitals, payers, and nursing representatives. In 2000, the Health Services Cost Review Commission (HSCRC) implemented the Nurse Support Program (NSP I) to address the issues of recruiting and retaining nurses in Maryland hospitals. In 2005, seventy-nine percent (79%) of the RN programs reported that they had met or exceeded their enrollment capacity. The shortage of qualified nursing faculty was identified as the fundamental obstacle to expanding the enrollments in nursing programs, thereby exacerbating the nursing shortage. The Health Services Cost Review Commission proactively created the NSP II to address the barriers to nursing education through statute with the Annotated Code of Maryland, Education Article § 11-405. Nurse Support Program Assistance Fund. At its May 4, 2005, public meeting, the HSCRC unanimously approved an increase of 0.1% of pooled regulated gross patient revenue for use in expanding the nursing workforce through increased nursing faculty and nursing program capacity in Maryland. On March 7, 2012, HSCRC approved modifications to NSP II to include increased doctoral education support for greater development of new and existing nursing faculty.

At the conclusion of the original ten years of funding, the HSCRC and MHEC staff completed a comprehensive program evaluation with the assistance of an NSP II Advisory Board. This Health Services Cost Review Commission's report is public and available on pages 100-107 at HSCRC NSP II Report January 2015. Many stakeholders provided letters of support. The data provided by NSP II competitive institutional grant project directors suggest that over 5,800 or 27% of all undergraduate nursing degrees produced between 2006-2013 are directly attributable to the NSP II competitive institutional grant program focused on increased graduations of pre-licensure RNs through redesigned curriculum options and new programs.

The HSCRC approved an additional 5 years of funding with recommendations to update the statute to better reflect nurses with the skills necessary to keep pace with the rapidly changing health care delivery system. At the conclusion of the first ten years of funding on January 14, 2015, the most recent NSP II renewal was approved. The NSP II was renewed for five years for FY 2016 through June 30, 2020. Senate Bill (SB) 1081 was passed by both the Maryland Senate and House to delete the term “bedside" from the descriptor of nurses in the statutory provision establishing the NSP II and signed by Governor Hogan on April 26, 2016.

In 2019, at the conclusion of the approved FY 2016-FY 2020 period of funding, the HSCRC and MHEC staff completed a comprehensive program evaluation with the assistance of an NSP II Advisory Board. This Health Services Cost Review Commission's December 2019 report is public and available at the HSCRC Commission Meeting Schedule.

Annotated Code of Maryland, Education Article
§ 11-405. Nurse Support Program Assistance Fund (a) "Fund" defined.- In this section, "Fund" means the Nurse Support Program Assistance Fund. (b) Established; status; administration; investments.- 1. There is a Nurse Support Program Fund in the Commission. 2. The fund is a continuing, nonlapsing fund that is not subject to §7-302 of the State Finance and Procurement Article 3. The Treasurer shall separately hold and the Comptroller shall account for the fund 4.The fund shall be invested and reinvested in the same manner as other State funds 5. Any investment earnings of the fund shall be paid into the fund (c) Composition.- The Fund consists of revenue generated through an increase, as approved by the Health Services Cost Review Commission, to the rate structure of all hospitals in accordance with § 19-211 of the Health - General Article. (d) Expenditures.- Expenditures from the Fund shall be made by an appropriation in the annual State budget or by approved budget amendment as provided under § 7-209 of the State Finance and Procurement Article (e) Use of money; guidelines.- The money in the Fund shall be used for competitive grants and statewide grants to increase the number of qualified nurses in Maryland hospitals in accordance with guidelines established by the Commission and the Health Services Cost Review Commission. (f) Guideline provision for minority recruitment. - The guidelines established under subsection (e) of this section shall provide that a portion of the competitive grants and statewide grants be used to attract and retain minorities to nursing and nurse faculty careers in Maryland. [2006, chs. 221, 222.][2016]

Goals of the NSP II

In 2010, The Institute of Medicine (IOM) released the report The Future of Nursing: Leading Change, Advancing Health. Nursing leaders organized in response to the clear action-oriented blueprint outlined in the 4 key messages and 8 recommendations identified by the IOM Committee. Nurses make up the single largest segment of the health care work force, estimated at 3 million nationally. They spend the most time delivering patient care. Therefore, they have invaluable insights and unique abilities as contributing partners with other health professionals in leading improvements in the quality and safety of care. While the nursing profession widely acknowledges the value of the IOM report, The American Journal of Nursing recognized the publication with the 2011 Book of the Year Award. It explores how nurses' roles, education, responsibilities and competencies should change significantly to meet the increased demand for care that will be created by health care reform and advance the improvements in an increasingly complex health care system. These competencies include leadership, rapidly advancing technology, information management, system improvements, health policy, evidence-based practice, research, increased case management and community based health delivery. All of these are needed for increasingly complex care decisions to be coordinated within a collaborative interdisciplinary team. Since then, the recommendations have evolved and Assessing Progress on the IOM report, The Future of Nursing (2015) was released with additional guidance.

NSP II programs support the goals within the key messages of an improved educational system that promotes seamless academic progression, with higher levels of education and better information infrastructure for workforce planning and policy making.

The Need for Highly-Educated Nurses and an Improved Education System

Improving the education system and achieving a more educated workforce—specifically increasing the number of nurses with baccalaureate degrees—can be accomplished through a number of different programs and educational models, including: traditional RN-to-BSN programs; traditional 4-year BSN programs; collaborative educational partnerships to allow for automatic and seamless transitions from an ADN to a BSN; new providers of nursing education; simulation and distance learning through online courses; and academic-service partnerships. New approaches and educational models are needed to ensure curricula are readily adaptive to increasing technological and evidence-based changes in patient care.

In addition to increased numbers of BSN-educated nurses, schools of nursing must build their capacities to prepare more students at the graduate level who can assume roles in advanced practice, leadership, teaching, and research. While 13 percent of nurses hold a graduate degree, fewer than one percent have a doctoral degree. Nurses with doctorates are needed to teach future generations of nurses and to conduct research that becomes the basis for improvements in nursing science and practice. Recently, the Maryland Board of Nursing collaborated on an IOM committee survey to determine that approximately 600 nurses with doctorates practice in Maryland. Multiple partnerships and programs have joined in the effort to increase educational preparation for nurses to fill faculty roles, serve in joint clinical and faculty appointments and meet the needs of future students who will be entering the profession as Registered Nurses.

Four of the Future of Nursing 2010 Recommendations are deeply embedded in the programs of NSP II:

Select a Nursing Program

Nursing Faculty Programs

• Increase the proportion of nurses with a baccalaureate degree to 80 percent by 2020.
• Double the number of nurses with a Doctorate by 2020.
• Ensure that nurses engage in lifelong learning.
• Build an infrastructure for the collection and analysis of inter-professional health care workforce data.

NSP II added #5 -#7 with the FY 2020 program evaluation:

• Double the number of full-time nurse faculty credentialed by the National League for Nursing as Certified Nurse Educators by 2025.
• Engage NSP I and NSP II leadership in finding solutions to mutual priorities.
• Increase the number of nurse participants from hospitals from both academic and practice settings in NSP II funded statewide initiatives like the Nurse Leadership Institute, Maryland Clinical Simulation Resources Consortium, Faculty Academy and Mentorship Initiative and others available to nurses at hospitals, health systems and academic nursing programs.

The NSP I and II Advisory Board agreed to work together to address the issues of nurse retention and nurse turnover in new and experienced nurses in FY 2021-2025.

This work builds on the foundation set out by The Future of Nursing: Leading Change, Advancing Health (2011) report.

Latest report is:
National Academy of Medicine 2022. Emerging Stronger from COVID-19: Priorities for Health System Transformation. Washington, DC: The National Academies Press.

The Maryland Hospital Association's Task Force on Maryland's Future Health Workforce released an extensive report earlier this month outlining recommendations to combat the state's critical workforce shortage. Recent data from a 2022 GlobalData report, commissioned by the Maryland Hospital Association, reveals there is a statewide shortage of about 5,000 full-time registered nurses and 4,000 licensed practical nurses. Without intervention, the GlobalData report shows shortages could more than double by 2035.

The report provides specific recommendations that fall into 4 categories: expanding the workforce pipeline, removing barriers to health education, retaining the health workforce, and leveraging talent with new care models. The task force specifically recommends that hospitals and health systems commit to making additional clinical training sites available, partner with community-based organizations for local workforce development, and ensure that wellbeing and inclusion are embedded in organizational values.

Administration, Application Process, Implementation and Evaluation

Nursing programs submit proposals for grant projects that address their specific educational needs. A multi-stakeholder evaluation committee reviews the proposals and works with designated institutional project directors to ensure compliance with the original approved project with any changes supporting the overall goals of the NSP II. Nursing programs submit annual reports that describe measurable outcomes of their program along with annual budget reports. MHEC provides ongoing oversight through site visits, as well as coordination and approval of all program or budget revisions. Statewide initiatives require individual nominations and application submissions for graduate nurse faculty scholarships, faculty fellowships and nursing educator doctoral grants. These initiatives include concurrent or future expectations of a service commitment to a Maryland nursing program in a faculty role. Funding is provided by the Health Services Cost Review Commission through 0.1% of the hospital's gross regulated patient revenue for the previous year. Program evaluations are summative, based on outcomes reported through each awarded institution and grantee. Annual reports and recommendations are submitted by NSP II program staff to the Health Services Cost Review Commission.

Code of Maryland, Education Article § 11-405. (2016).

The All-Payer Pricing Alternative by Merrill Goozner, June 21, 2021 Washington Monthly

Only one state in the nation avoids cross-subsidization pricing and, as a result, can offer insurance plans to uninsured individuals and families on its exchange that are among the least costly in the nation.

Since 1974, Maryland has maintained a price-setting regulatory authority for health services that is similar in function to the commissions in every state that regulate natural gas and electricity prices. In 1977, the state and its Health Services Cost Review Commission was one of five that received federal government permission to set up a hospital pricing system where all payers – including Medicare and Medicaid – pay the same rate for the same service at any given hospital in the state.

Different hospitals are allowed to charge different rates based on their historic baselines. But individual hospitals cannot charge different patients different rates based on the insurance card they carry. It's called all-payer pricing. Maryland is the only state that has kept the system. (Goozner, 2021)

Washington Monthly June 17, 2021

NURSE EDUCATION SUPPORT SINCE 1986

Dr. Hal Cohen was the first Executive Director of the Maryland Health Services Cost Review Commission (HSCRC) from 1971 to 1987.
Under his leadership, the original Nurse Education Support Program (NESP) in 1986 was funded. It transitioned to the Nurse Support Program I (NSP I) in 2000 and Nurse Support Program II (NSP II) in 2005. Both of these NSP programs are funded through the HSCRC to address the nursing workforce shortage with a two-pronged approach from the practice settings at hospitals/ health systems (NSP I) and the academic nursing education programs (NSP II).

Under Dr. Cohen's leadership, Maryland was the only state out of five states with the opportunity to pilot the Medicare waiver in the late 1970's and successfully maintain it. The rules of the model provided for all patients to be charged the same amount for the same care. The HSCRC, as the rate setting agency for the state, has worked through revisions to the model to ensure that hospital costs and the costs of care are kept low, without impacting high quality and full accessibility.

On January 1, 2014, the State of Maryland and the Centers for Medicare & Medicaid Services (CMS) entered into a new initiative to modernize Maryland's unique all-payer rate-setting system for hospital services. The Center for Medicare and Medicaid Innovation (CMMI) oversees the Model under the authority of CMS. This initiative, replacing Maryland's 36-year-old Medicare waiver, allows Maryland to adopt new and innovative policies aimed at reducing per capita hospital expenditures and improving patient health outcomes. Success of the New All-Payer Model will reduce cost to purchasers of care—businesses, patients, insurers, Medicare, and Medicaid—and improve the quality of the care that patients receive both inside and outside of the hospital.

Maryland is the only state in the nation to maintain a model, where every payer pays the same charge for the same care. As the rate setting agency for the State, the HSCRC plays a vital role in the implementation of the Total Cost of Care Model.

Dr. Peg E. Daw, DNP, RN-BC, CNE, FAAN
Former Nurse Support Program II (NSP II) Grant Administrator