Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants

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Author(s):

Thomas V. Caprio, MD

INTRODUCTION

Nursing homes have a variety of organized medical services ranging from exclusive on-site physician groups to open models of community-based attending physicians. There also appears to be a small physician workforce engaged in the care of nursing home residents, and some have suggested that physician staffing patterns can be important influences on the quality of care delivered in nursing homes.1 Concerns have also been raised regarding a lack of physician involvement in nursing home medical practice, especially in a pressured health care environment that places emphasis on time and performance. The Institute of Medicine highlighted similar concerns in 1986 with a critical report on the quality of care in nursing homes that also raised questions regarding the supervision of medical services.2 This has resulted in an increasingly regulated environment for nursing homes. Along with the growing medical complexity and increasing numbers of older adults potentially requiring long-term care, there will likely be a further strain on the physician workforce available for nursing homes.

To meet some of the workforce needs, attention has focused on the increasing role of nurse practitioners (NPs) and physician assistants (PAs) to enhance the medical care in nursing homes. Historically, the physician medical community has attributed the term physician extenders to NPs and PAs. However, this term has not been fully embraced by the practitioners themselves, and it does not provide an adequate description of the NP or PA role in the health care system. Other terms such as mid-level providers or mid-level practitioners are also used, and have an implication of both a medical hierarchy and differences in licensing or certification requirements for the professions, as compared to physicians. A more widely accepted term for nurse practitioners is advanced practice nurses, which provides a more accurate acknowledgment of the additional training and certification requirements within an expanded scope of nursing practice. Advanced practice nurses (APNs) encompass a broad range of individuals including nurse practitioners, clinical nurse specialists, certified nurse midwives, and certified registered nurse anesthetists.3

A comprehensive review of physician extenders in the nursing home by Aaronson in 1991 has carefully documented the evolution of NPs and PAs in the context of nursing home medical organization.4 Since that time, there has been continued growth in the workforce of nurse practitioners and physician assistants, with increasing representation in nursing home medical practice. The American Academy of Nurse Practitioners survey in 2004 estimates there are over 100,000 NPs in the U.S., with 13% having privileges in long-term care; in practice, as little as 2% may actually be in nursing home settings.5,6 Findings from the U.S. Department of Health and Human Services National Sample Survey of Registered Nurses places the estimate at about 68,000 NPs in all practice settings.6 The American Academy of Physician Assistants census of 2005 reports more than 66,000 PAs eligible to practice in the U.S., with less than 10% working in nursing homes or other long-term care settings.7

A nursing home may employ a variety of other APNs, in addition to primary care NPs. The use of clinical nurse specialists (CNSs) with expertise in geropsychiatry or wound care has been an important and growing presence in geriatric care settings. (This group of practitioners will not be discussed here in an effort to focus specifically on primary medical care providers.)

The physician staffing relative to the NP or PA workforce has not been adequately described, but it is clear that the collaboration with these providers is a relevant and an evolving influence on physician practice in the nursing home.

References:

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