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