Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants
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Thomas V. Caprio, MD
Hartford Foundation Institute for Geriatric Nursing convened an expert panel to examine ways to strengthen the use of APNs in nursing homes.8 The panel recommendations ranged from enhanced geriatric content in education to changes in reimbursement for traditionally nonbillable activities (eg, communication and care planning), and recommended caseloads for individual NPs. The NP caseload can vary greatly depending on the acuity of nursing home residents receiving care. The Evercare managed care organization, which utililizes NPs as the cornerstone of their care delivery model, has reported total caseloads between 80-110 residents, on average.19 The Hartford Foundation expert panel addressed the daily workload of NPs with a recommendation of no more than 12-18 reimbursable visits to nursing home residents per workday, above which the quality of care provided is questioned.8
The Centers for Medicare & Medicaid Services (CMS) has established regulations regarding the physician delegation of tasks to mid-level practitioners in both skilled nursing facilities (SNFs) and nursing facilities (NFs).20 The major distinction between allowed activities of mid-level practitioners depends both on the care setting (SNF or NF) and the employment relationship between the facility and the NP or PA. The employment of mid-level practitioners by a facility has raised the question of a potential conflict of interest during the certification process of residents to the facility under Medicare or Medicaid; this prompted CMS to formulate regulations governing clinical activities. These regulations have been the source of some confusion within the long-term care community, causing CMS to issue clarifications in late 2003.15,20,21 The essential points of the regulations are summarized below:
• All NPs and PAs are allowed to perform medically necessary services to residents regardless of the care setting and within the scope of practice defined by the State.
• In SNFs, only the physician can perform the full initial comprehensive visit in which a history, physical examination, assessment, and a care plan are formulated.
• Physician assistants are not authorized to sign the initial certification or recertifications in SNFs; however, a nurse practitioner who is not an employee of the SNF may sign the certification or recertifications subject to State requirements.
• A physician may delegate alternate follow-up visits required by regulations (usually 30- or 60-day resident evaluations subsequent to the admission) to a collaborating NP or PA in the SNF.
• For the care of nonskilled nursing facility residents, the employment by the facility is the important determinant of the scope of practice for mid-level practitioners as determined by CMS. Wide latitude is generally given to NPs and PAs to substitute for the physician in the NF and perform the initial comprehensive visit, subsequent required visits, certification, and recertification, as long as they are not an employee of the facility, are working in collaboration with a physician, and are subject to individual State regulations regarding scope of practice.
Most studies have traditionally examined the NP and PA role in providing community-based primary care.4 The primary care practice in nursing homes by these providers only recently has been described, and considerable gaps in knowledge still remain. Nurse practitioners remain the best described in the nursing home as compared to PAs, due in part to a greater presence in long-term care and a longer history of the profession. Additionally, traditional NP training has emphasized advancement through graduate-level education programs anchored in schools of nursing, potentially fostering an academic environment for research and incentives for publishing clinical outcomes.
References 1. Karuza J, Katz PR. Physician staffing patterns correlates of nursing home care: An initial inquiry and consideration of policy implications. J Am Geriatr Soc 1994;42(7):787-793. 2. Committee on Nursing Home Regulation Institute of Medicine. Improving the Quality of Care in Nursing Homes. Washington, DC: National Academy Press; 1986. 3. Phillips SJ. A comprehensive look at the legislative issues affecting advanced nursing practice. Nurse Pract 2005;30(1):14-47. 4. Aaronson WE. The use of physician extenders in nursing homes: A review. Med Care Rev 1991;48(4):411-447. 5. American Academy of Nurse Practitioners. Nurse Practitioner Workforce Data Survey 2004. Available at: http: //www.aanp.org/NR/rdonlyres/exenwjnl3eybaktqli266uvk4kw364gapgzjhyyvey2d7fziiv2uhd55atxojxgdjrp3q5vu4e6akp/NPStateWorkforceData1204.pdf. Accessed January 3, 2006. 6. Spratley E JA, Sochalski J, Johnson A. Findings From the National Sample Survey of Registered Nurses. U.S. Department of Health and Human Services, Health Resources and Service Administration, Bureau of Health Professions, Division of Nursing. Available at: http: //bhpr.hrsa.gov/healthworkforce/reports/rnsurvey/default.htm. Accessed January 3, 2006. 7. American Academy of Physician Assistants. 2005 AAPA Physician Assistant Census Report. Available at: http: //www.aapa.org/research/05census-content.html. Accessed January 3, 2006. 8. Mezey M, Greene Burger S, Bloom HG, et al. Experts recommend strategies for strengthening the use of advanced practice nurses in nursing homes. J Am Geriatr Soc 2005;53(10):1790-1797. 9. Bottom WD. Geriatric medicine in the United States: New roles for physician assistants. J Community Health 1988;13(2):95-103. 10. Mendenhall RC, Repicky PA, Neville RE. Assessing the utilization and productivity of nurse practitioners and physician’s assistants: Methodology and findings on productivity. Med Care 1980;18(6):609-623. 11. Tourigny A, Aaronson W. The Efficacy of the Use of Physician Extenders in Nursing Homes. (Funded through a grant from the Retirement Research Foundation.) Alexandria, VA; Foundation of the American College of Health Care Administrators; 1989. 12. Aaronson WE. Is there a role for physician extenders in nursing homes? J Long Term Care Adm 1992;20(3):18-22. 13. Resnick B, Bonner A. Collaboration: Foundation for a successful practice. J Am Med Dir Assoc 2003;4(6):344-349. 14. Ebersole P, Smith A, Dickey EW, Gamroth L. Roles and functions of geriatric nurse practitioners in long term care as viewed by physician, GNP and administrator. J Am Health Care Assoc 1982;8(2):2-7. 15. Rapp MP. Opportunities for advance practice nurses in the nursing facility. J Am Med Dir Assoc 2003;4(6):337-343. 16. Intrator O, Feng Z, Mor V, et al. The employment of nurse practitioners and physician assistants in U.S. nursing homes. Gerontologist 2005;45(4):486-495. 17. Rosenfeld P, Kobayashi M, Barber P, Mezey M. Utilization of nurse practitioners in long-term care: Findings and implications of a national survey. J Am Med Dir Assoc 2004;5(1):9-15. 18. Stefanacci RG. Will nurse practitioners replace physicians as attendings in long-term care? J Am Med Dir Assoc 2001;2(5):222-224. 19. Kane RL, Huck S. The implementation of the Evercare demonstration project. J Am Geriatr Soc 2000;48(2):218-223. 20. Centers for Medicare & Medicaid Services. Department of Health and Human Services. Memorandum from Director of Survey and Certification Group. Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs). Ref: 58C-04-08. November 13, 2003. Available at: www.health.state.nd.us/PDF_files/sc0408.pdf. Accessed January 3, 2006. 21. LaPorte M. CMS clarifies physician use of mid-level paractitioners. Caring for the Ages 2003;4(9):4. Available at: http: //www.amda.com/caring/september2003/midlevel.htm. Accessed January 3, 2006. 22. Melillo KD. Utilizing nurse practitioners to provide health care for elderly patients in Massachusetts nursing homes. J Am Acad Nurse Pract 1993;5(1):19-26. 23. Bynum GD, Jelinek D, Smith J. A medical director’s view of the GNP in the nursing home. J Long Term Care Adm 1983;11(3):34-35. 24. Garrard J, Kane RL, Radosevich DM, et al. Impact of geriatric nurse practitioners on nursing-home residents’ functional status, satisfaction, and discharge outcomes. Med Care 1990;28(3):271-283. 25. Rauckhorst LM. Impact of a physician/nurse practitioner team primary care delivery model on selected geriatric long-term care outcomes. J Nurs Qual Assur 1989;4(1):62-72. 26. Melillo KD. Nurse practitioners in long-term care: Perceptions of DONs. J Long Term Care Adm. Fall 1992;20(3):13-17. Erratum in: J Long Term Care Adm 1992;20(4): 17. 27. Katz PR, Karuza J. Physician practice in the nursing home: Missing in action or misunderstood. J Am Geriatr Soc 2005;53(10):1826-1828. 28. Aigner MJ, Drew S, Phipps J. A comparative study of nursing home resident outcomes between care provided by nurse practitioners/physicians versus physicians only. J Am Med Dir Assoc 2004;5(1):16-23. 29. Kane RL, Garrard J, Skay CL, et al. Effects of a geriatric nurse practitioner on process and outcome of nursing home care. Am J Public Health 1989;79(9): 1271-1277. 30. Kane RL, Garrard J, Buchanan JL, et al. Improving primary care in nursing homes. J Am Geriatr Soc 1991;39(4):359-367. 31. Mitchell SL, Teno JM, Roy J, et al. Clinical and organizational factors associated with feeding tube use among nursing home residents with advanced cognitive impairment. JAMA 2003;290(1):73-80. 32. Burl JB, Bonner AF. A geriatric nurse practitioner/physician team in a long-term care setting. HMO Pract 1991;5(4):139-142. 33. Schultz PR, McGlone FB. Primary health care provided to the elderly by a nurse practitioner/physician team: Analysis of cost effectiveness. J Am Geriatr Soc 1977;25(10):443-446. 34. Buchanan JL, Bell RM, Arnold SB, et al. Assessing cost effects of nursing-home-based geriatric nurse practitioners. Health Care Financ Rev 1990;11(3):67-78. 35. Fama T, Fox PD. Efforts to improve primary care delivery to nursing home residents. J Am Geriatr Soc 1997;45(5):627-632. 36. Burl JB, Bonner A, Rao M, Khan AM. Geriatric nurse practitioners in long-term care: Demonstration of effectiveness in managed care. J Am Geriatr Soc 1998;46(4):506-510. 37. Burl JB, Bonner A, Rao M. Demonstration of the cost-effectiveness of a nurse practitioner/physician team in long-term care facilities. HMO Pract 1994;8(4):157-161. 38. Intrator O, Castle NG, Mor V. Facility characteristics associated with hospitalization of nursing home residents: Results of a national study. Med Care 1999;37(3):228-237. 39. Ackermann RJ, Kemle KA. The effect of a physician assistant on the hospitalization of nursing home residents. J Am Geriatr Soc 1998;46(5): 610-614. 40. The Heart of Caring. Available at: http: //www.theheartofcaring.com/aboutEvercare.htm. Accessed January 3, 2006. 41. Kane RL, Keckhafer G, Robst J. Evaluation of the Evercare Demonstration Program Final Report. Centers for Medicare and Medicaid Services, Demonstration Projects & Evaluation Reports. Available at: http: //new.cms.hhs.gov/DemoProjectsEvalRpts/downloads/Evercare_Final_Report.pdf. Accessed January 3, 2006. 42. Kane RL, Flood S, Keckhafer G, Rockwood T. How Evercare nurse practitioners spend their time. J Am Geriatr Soc 2001;49(11):1530-1534. 43. Kane RL, Flood S, Keckhafer G, et al. Nursing home residents covered by Medicare risk contracts: Early findings from the Evercare evaluation project. J Am Geriatr Soc 2002;50(4):719-727. 44. Kane RL, Keckhafer G, Flood S, et al. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51(10):1427-1434. 45. Abdallah L, Fawcett J, Kane R, et al. Development and psychometric testing of the Evercare Nurse Practitioner Role and Activity Scale (ENPRAS). J Am Acad Nurse Pract 2005;17(1):21-26. 46. Abdallah LM. Evercare nurse practitioner practice activities: Similarities and differences across five sites. J Am Acad Nurse Pract 2005;17(9):355-362. 47. Kane RL, Flood S, Bershadsky B, Keckhafer G. Effect of an innovative Medicare managed care program on the quality of care for nursing home residents. Gerontologist 2004;44(1):95-103. 48. Rector TS, Spector WD, Shaffer TJ, Finch MD. Pneumonia in nursing home residents: Factors associated with in-home care of Evercare enrollees. J Am Geriatr Soc 2005;53(3):472-477.