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

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Author(s):

Thomas V. Caprio, MD

Research has sought to demonstrate either better quality of care delivered by mid-level practitioners compared to physician providers alone, or equivalency with physician practice in the nursing home. Both of these objectives remain consistent with the previously described model of a “physician extender,” in which substitutability remains the primary goal. Much less is known about collaboration between a physician and NP or PA in current research. Some studies suggest that the process of care can be enhanced by this type of collaboration of physician and mid-level practitioner, beyond what might occur with substitution of the physician provider alone.22 A major obstacle in comparing research outcomes is that it remains unknown what should constitute “usual care” within the nursing home. Depending on physician staffing, models of medical staff organization, and standards used to measure quality, the benchmark for comparison may be an elusive target.

Physician medical directors of nursing homes report a high degree of satisfaction from NP utilization, as perceived by attending physicians, residents, nursing staff, and families.17,23 Other studies have shown no significant difference in reported satisfaction from residents or family when care is provided by NPs.24,25 A survey of directors of nursing in long-term care facilities has described NPs as fulfilling a complementary role to that of the nursing staff, and report less hospitalization, more prompt responses to identified problems, and more complete documentation as a result of NP presence.26 Some have argued that it is possible that on-site nursing home physicians and closed-staffing models of medical organization would obtain improved satisfaction and clinical results due to greater physician availability, commitment, and knowledge.27 Further research is needed in order to fully understand how the types of physician staff organization and integration of NPs and PAs with medical services influences clinical outcomes for nursing home residents.

There does appear to be increased medical attention (defined as number of visits and medical orders) to nursing home residents when primary care is provided by NPs and PAs.28-30 In addition, better scores have been reported on some quality indicators, as compared to physicians, for congestive heart failure, hypertension, and new urinary incontinence.30 Specific process of care measures indicate that NPs may perform better with skin care, decubitus ulcer prevention, incontinence, diabetic foot care, and congestive heart failure assessments, when compared to a physician-only model of care.22

A variety of other interesting clinical outcomes have been described in the literature with the implementation of mid-level practitioners (Table). One study describes a reduction in medication prescribing and the utilization of laboratory services, as well as a greater proportion of residents being discharged to home when care is coordinated by a NP.29 There have been mixed results regarding the effect on resident functional status, with most studies showing only minimal influence by NPs on a resident’s potential functional decline.24,29,30 There may be significant impact on end-of-life care, as facilities with NPs or PAs on staff are less likely to use feeding tubes in residents with advanced cognitive impairment. In addition, completion rates for Do-Not-Resuscitate and Do-Not-Hospitalize orders may be higher with NP collaboration.31,32 This may be related to the provider’s greater availability or more frequent communication with residents and families regarding advance directives.

COST-EFFECTIVENESS

The reduction in hospitalizations is a source of potential cost savings and serves as the primary focus in cost-effectiveness research for the utilization of NPs and PAs.

References:

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