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

Fri, 9/5/08 - 5:54pm
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Author(s):

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.

CLINICAL OUTCOMES

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:

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