Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants
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Thomas V. Caprio, MD
In addition to these clinical studies and program reports, it is important to consider that Evercare has played a valuable part in helping to define the role of the NP in the nursing home. Emphasis has been placed on the NP as a communicator and care coordinator, who also plays a role in the education of nursing home staff.45,46 This integration into care teams has been a key ingredient in Evercare’s success in maintaining enrollment and reducing hospitalizations. Reports of time distribution of Evercare NPs indicate that over one-third of their time is spent in direct patient care, and the majority of remaining time is spent on communication with physician, staff, and family.42
Evercare also has extended benefits to the attending physician through this collaboration with NPs. It has provided innovative methods of reimbursement to physicians for traditionally nonbillable activities, such as meetings with families and attendance at care-planning conferences. The lesson provided by Evercare may be that successful collaboration can result in a health care system that maximizes providers’ skill sets and provides reimbursement incentives. While it remains to be demonstrated whether this approach to organizing medical services in nursing homes can be generalized nationally, the Evercare concept has now been established as a national benchmark to measure subsequent physician and NP collaborative practice.
It is clear that ongoing physician collaboration with NPs or PAs will continue in nursing home medical practice. It may become a matter of necessity, as the nursing home–eligible population grows and facilities seek to expand the accessibility and quality of medical services. If enhanced quality of care can continue to be demonstrated through outcomes research, the NP and PA collaboration with physicians may become a standard of care and a target for future government regulation. Priorities will need to be established for research, policy, and education directed towards refining this model of care. Particular attention will need to be paid to the role and activities of PAs, which have been the focus of far less research in long-term care as compared to the NP.
Building on collaborative NP and PA practice, it will be important to consider how this integration of specific duties and complementary skills with physicians can achieve enhanced medical care delivery and clinical outcomes. Unfortunately, no consensus has been achieved regarding the role definition of each profession. Future research will need to address the unique skills and training that each provider possesses, and how each profession can best be utilized in nursing home medical practice. Furthermore, investigation will need to focus on how collaboration affects the process of care, specifically including time and costs that will be of great interest to facilities and payers.
The outcomes measures chosen for future research will largely depend on how quality of care is defined and measured in nursing homes. The current measures of quality have mostly been driven by regulatory standards of care. While some in the field may advocate a theoretical substitution of physicians by mid-level providers, the fundamental solution to quality concerns most likely rests upon both an enhanced provider workforce as well as redefining the delivery of care by all providers. The current regulatory architecture is based on a physician-centered medical model of care that may not capitalize on the unique skill sets that physicians, NPs, and PAs possess in the delivery of care to nursing home residents.
Physicians practicing in nursing homes will need to understand their evolving role in medical staff organization, and how to best utilize the skills and talents of each member of the medical team.
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