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Long-Term Care Survey Alert

Quality Improvement:

A Physician Extender Visit A Day Can Keep Hospitalizations Away

Published on Tue Jul 31, 2012 Print Friendly and PDF PDF

Use of PAs/NPs in nursing facilities reduces ED visits and hospital readmissions.

Nursing homes looking for ways to cut down on their patients' visits to emergency departments and hospitalizations should consider the daily use in their facilities of physician extenders, such as physician assistants (PAs), advanced practice nurses (APNs), and nurse practitioners (NPs). Read on to see if this professional staff model could work in your facility.

Why might you consider enhanced team models and roles for your facility? "Well," says Alice Bonner, RN, PhD, CMS' director of the division of nursing homes, survey and certification group, "there is a growing body of evidence that long term care residents benefit from these kinds of models, specifically improved clinical outcomes, lowered hospitalization rates and decreased costs (see the CMS Special Study on Potentially Avoidable Transfers box on pg. 58 of this issue).

Tae Joon Lee, MD, CMD, medical director for Golden Living Center in Greenville, North Carolina agrees. "Research has shown that nursing facilities that have a physician, NP or PA to see patients at least three times a week in the building are much less likely to end up with their patients being admitted to the hospital," he notes.

Provide needed treatments

The reason for this is fairly simple and straightforward. "Most nursing homes today have the capacity to take care of many of the conditions, such as pneumonia, bronchitis, UTIs, and CHF exacerbations, which are the cause of the ED visit and/or hospital admission. But if there is no provider available in the facility to examine the patient and plan out the care, then the easiest thing for the staff to do is send them to the hospital," Lee explains.

Lee's facility employs a full-time nurse practitioner who works from 8am to 5pm Monday through Friday. "When she first comes into the building, even before she drops her stuff down in the office, she goes around and asks every single nurse down each hallway, 'Is there anybody sick? Is there anybody who needs to be looked at today?' These individuals then become our priority and we make sure that we examine them that day," Lee notes.

Night/weekend coverage: But what about nights and weekends when the NP isn't there? Because Golden Living Center is a teaching facility associated with East Carolina University (ECU), they also have access to geriatric fellows, NPs and PAs who take turns carrying the nursing home pager. "We encourage these providers to come and see the patient over the weekend, and we provide a financial incentive for the NPS to do that because they will get reimbursed for the visit," Lee explains.

Communicate and collaborate

As important as enhanced professional staffing is, though, communication and collaboration is equally vital. "When we asked experts what resources are needed to manage people in the nursing home, they focused very much on enhanced collaboration," notes Bonner. "Some of the common themes with collaborative relationships include a focus on collegial relationships, team work, open communication, recognition of one another's expertise, respect and trust," she adds.

Everybody talks: "Ultimately this is really about communication, and communication is the key to effective collaboration. When new providers are going to be working together, particularly external providers coming into a facility, it's so important that everyone talks about who's going to do what, where the responsibilities and accountabilities are," Bonner says.

"For example, things like on call and coverage issues. Who's going to take calls at certain time? How are sign-outs going to be done, vacations, etc.? What are the practice philosophies, and how well-aligned are the providers who are going to be working together? Is a provider going to be available for consultation during the middle of the day? What if either the physician or the nurse practitioner is busy in the office? Are they going to be able to go out to the nursing home to see someone?," Bonner posits.

Lee agrees that effective communication among the various parties involved is essential. "I would say that over half of it is all about communicating. There needs to be close communication between the facility's providers and staff, between the providers and family members, and between the hospital provider and the nursing home provider."

Establish NP collaborative agreements

Specifically, in developing collaborative relationships with nurse practitioners, Bonner notes, it is important to understand that the majority of nurse practitioners work in states that require a collaborative agreement with a physician. These agreements are very much guided by the individual state's Nurse Practice Act and regulation through the Board of Medicine and the Board of Nursing, so you need to know the scope of practice for the NP in your state, she emphasizes.

Roles and responsibilities: "The collaborative practice agreement should establish the roles and responsibilities of all the parties, optimize the roles of each and build on the strengths of the nurse practitioner and the physician, and what each of them can bring to the roles," Bonner says. In structuring collaborative agreements, she recommends keeping the guidelines fairly general, "except for specific procedures, such as if the nurse practitioner is going to be suturing or something like that." Providers should also avoid setting time frames that are too constrained and make it realistic.

And, of course, all parties should read, sign and adhere to the agreement. "Make sure you are documenting evidence of adherence," Bonner emphasizes. "So for example, if it says in the collaborative agreement that the physician is going to review a nurse practitioner's narcotic-prescribing, which is fairly common, then there needs to be a way, a process for demonstrating to regulators that this is happening."

Prepare for the future

Lee acknowledges that the current Medicare reimbursement structure does not necessarily support the added costs that nursing facilities will incur in adopting this model of care. However, he notes, CMS has noticed that "it costs a lot of money to take care of nursing home patients that go back and forth between the nursing facility and the hospital." As a result, the agency is actively exploring changes, such as bundled payments and value-based purchasing, that will punish facilities that have unnecessary ED visits and hospitalizations.

"In reality nursing facilities have a lot of restrictions and disincentives right now, but under the right circumstances, we have shown that we can do a lot better. We need to be working towards this in the future, because it leads to cost savings for the health care system as a whole and better patient outcomes," Lee concludes.

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