NP in LTC Flashcards
how are APNs reimbursed in LTC in relation to physicians?
reimbursed at 85% of physician rate for same services
by whom may an APN in a LTC facility be employed?
- by NH
- work for affiliated physician or group practice
- by MCO
what are some other duties APNs may have beyond clinical care?
- administration
- education
- nursing consultation
what is the primary goal of care for NH residents?
- improve or maintain functional status
- stabilize medical conditions
- deliver dignified end-of-life care
- high risk for re-hospitalization
what services do APNs provide in LTC?
- sick/urgent visits
- preventative care/monthly visits
- wound care
- end-of-life care
- psychiatric consultation
what organization has established regulations regarding delegation of tasks to NPs and PAs?
CMS (centers for medicare and medicaid)
what are some factors that effect delegation of tasks to NPs?
- care setting: SNF vs NF
- employment of NP by facility
what is the typical case load of NPs in LTC?
- varies depending on practice structure
- some facilities have reported 80-110 residents
may NPs employed by the facility perform/sign the initial comprehensive visit (H&P) in SNFs?
no
may NPs NOT employed by the facility perform/sign the initial comprehensive visit (H&P) in SNFs?
no
may NPs employed by the facility perform/sign the initial comprehensive visit (H&P) in NFs?
no
may NPs NOT employed by the facility perform/sign the initial comprehensive visit (H&P) in NFs?
YES
may NPs employed by the facility perform other required visits in SNFs?
yes, but alternate visits
may NPs NOT employed by the facility perform other required visits in SNFs?
yes, but alternate visits
may NPs employed by the facility perform other required visits in NFs?
NO
may NPs NOT employed by the facility perform other required visits in NFs?
yes
may NPs employed by the facility perform/sign other medically necessary visits and orders in SNFs?
yes
may NPs NOT employed by the facility perform/sign other medically necessary visits and orders in SNFs?
yes
may NPs employed by the facility perform/sign other medically necessary visits and orders in NFs?
yes
may NPs NOT employed by the facility perform/sign other medically necessary visits and orders in NFs?
yes
may NPs employed by the facility sign certification/recertification in SNFs?
no
may NPs NOT employed by the facility sign certification/recertification in SNFs?
yes, if state allows
what are some major outcomes of using NPs in LTC?
- decreased health care utilization
- improved quality of care
in what particular areas is there decreased health care utilization due to use of NPs?
- ED
- specialty referrals
- acute hospitalization
- medication prescribing
- lab services
in what ways do we see an increased quality of care of residents from use of NPs in LTC?
- satisfaction of resident, families, physicians, NH staff
- medication attention, i.e. frequency of visits, frequency/timing of medical orders
- disease-specific quality indicators, i.e. CHF, HTN, incontinence
- preventive health quality indicators, i.e. decubitus ulcers, diabetic foot care
- end-of-life care, i.e. DNRs, feeding tubes, DNH
in what 6 areas can NPs strongly impact reduced hospitalizations?
- identifying residents at high risk for readmission
- modifying visit pattern to better manage high risk residents
- improving communication between nurses and providers
- improving communication between NH and acute care setting
- providing support to residents and families to impact clinical decision-making
- discussing advanced directives, code status, and hospice
what do studies show are some clinical outcomes of NPs in LTC?
- lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviors
- residents had improvements in meeting personal goals
- families had satisfaction with medical services
- provide RESIDENT AND FAMILY-CENTERED CARE
- enhanced quality of care
- better relationships with residents and families with better information and emotional support
- perception of improved availability and timeliness of care
- perception of preventing unnecessary hospitalization
how do NPs and MDs compare in terms of quality of care delivered in NHs?
- NPs provide comparable care that is both substitutive and complementary to that provided by MDs in LTC
- health screening rates were similar, although NPs had higher completion rates of advanced directives related to DNR orders
are NPs safe providers in LTC?
- in absence of physician oversight or supervision, NPs are safe providers and prescribers
- often prove to be more cautious - spend more time with patient and less likely to prescribe medication as only therapy or intervention
what is the evercare model and what is its goal?
- capitated $ paid for each NH enrollee
- underlying premise: enhanced primary care = reduced hospitalization
- intense management at NH by NP as well as use of intensive service days (ISD) which reimburses a facility for care for acutely ill residents vs. hospital
what do studies show about the effectiveness of the evercare model?
- reduction in acute care transfers
- mixed results on other clinical outcomes (functional status, falls, depression, preventive health, etc.)
what are the components of the admission visit and who performs this visit?
- performed by MD
- indicate reason for admission
- complete medical and surgical hx
- meds
- physical exam
- screening tools
- functional assessment
- risks assessments
- advance directives
- code status
- complete assessment and plan
- capacity for decision making
- rehab potential
when should the 1st visit after admission be completed and what should it include?
- within 30 days of admission
- should incorporate additional data obtained (hospital records, lab data, consults, and other tests)
- review and revise medical plan of care
how often should scheduled visits be completed and who completes these?
- every 30 days for 1st 90 days and at least once every 60 days thereafter
- most providers visit every 30 days
- visits usually will alternate between NP and physician
- considered timely if within 10 days of due date
what consists of acute visits? when are these completed?
- for illness or changes reported by nursing staff
- focused HPI
- exam
- tx plan
what consists of monthly visits?
- detailed assessment of of resident’s current problems,
- PE
- chart review
- staff interview
- observation of care
- documentation of visit
- consent for care
- communication of tx plan
what are the facility goals for nosocomial pressure ulcers?
< 5%
what are some of residents’ rights?
- access to health care including selection of medical provider
- privacy: visit should not occur in hallway or other public area, HIPAA
- consent: residents have the right to know the results of the visit as well as implications for care; they have the right to refuse care
- communication: findings, tx plan, referrals
what are some challenges that NPs face in the NH?
- obtaining hx from a cognitively impaired resident
- resident and staff routines that impact the timing of visits
- possible facility barriers that impact tx plan
what are some goals of care of the NP?
- provide timely, quality visits
- reduce meds
- reduce restraints
- reduce need for hospitalization
- address pain and recommend strategies
- recommend strategies to improve function
- be part of the team!
- involve resident/family in decision-making
- get involved in QI initiatives
