Role of APN in LTC Flashcards
Describe the historical role of APN in LTC
For over 25 years APNs have been authorized to provide Medicare services in LTC facilities
Reimbursed at 85% of physician rate for same services
APN may be employed by the nursing home, work for an affiliated physician or group practice, or be contracted by a managed care organization
APN duties may extend beyond clinical care to include administration, education, or nursing consultation
What is the primary goal of care for NH residents under care of APRN
Primary goal of care: improve or maintain functional status, stabilize medical conditions, deliver dignified end-of-life care
what percent of nursing homes have APRNs and what services do they provide?
20% nursing homes report having APNs providing medical care Other practice settings: ALF and CCRCs Provide services such as: Sick/urgent visits Preventive care/monthly visits Wound care End-of-life care Psychiatric consultation
What are essential points of regulations for NPs vs. MDs providing care in NH
APNs are allowed to perform medically necessary services to residents regardless of care setting and within their scope of practice as defined by state
In SNFs- only MD may perform initial comprehensive visit (H&P)
NP who is not an employee of facility may sign the certification or recertification
Physician may delegate follow-up visits required by regs (30- or 60-day) to collaborating APN
For non-skilled residents wide latitude is given for duties unless NP employed by facility
What outcomes are seen when NPs are utilized in NH?
Decreased health care utilization:
Emergency department
Specialty referrals
Acute hospitalization (Melillo et al. reported 26% reduction with implementation of NP)
Medication prescribing
Lab services
Decreased health care utilization:
Emergency department
Specialty referrals
Acute hospitalization (Melillo et al. reported 26% reduction with implementation of NP)
Medication prescribing
Lab services
Improved quality of care:
Satisfaction (resident, families, physicians, NH staff)
Medical attention (frequency of visits, frequency/timing of medical orders)
Disease-specific Quality Indicators (congestive heart failure, hypertension, incontinence)
Preventive Health Quality Indicators (decubitus ulcers, diabetic foot care)
End-of-Life Care (DNR, feeding tubes, DNH)
What does research indicate are effects of NPs on clinical outcome in NH?
lower rates of depression, urinary incontinence, pressure ulcers, restraint use, and aggressive behaviors; more residents who experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services.
How do NPs compare to MDs in terms of safety in NH care?
Literature review demonstrated that in the absence of physician oversight or supervision, advanced practice nurses (APRNs) are safe providers and prescribers, often proving to be more cautious, spending more time with the patient, and less likely to prescribe medication as the only therapy or intervention.
What is the Evercare model?
Started in 1987; Medicare demonstration project 1994
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
Studies: confirm reduction in acute care transfers; mixed results on other clinical outcomes (functional status, falls, depression, preventive health, etc.)
What are come implications of the Evercare model?
Evercare has played valuable part in defining role of NP in the NH
Emphasized NP as communicator, care coordinator, staff educator, and clinical role model
Validated role of NP in providing timely clinical care that has huge practice and policy implications
Need to emphasize that we should not overlook the basic components of the monthly visit that assist in the detection of changes in mood, functional decline, weight changes, skin, and end of life care.
What is the NH Admission visit, components, and who does it?
Admission Visit: performed by MD. Should indicate reason for admission; complete medical social, surgical hx; meds; physical exam; screening tools used; functional assessment.
Review of risk assessments (Braden, falls, etc.)
Advance Directives
Code Status
Complete assessment and plan
Capacity for Decision Making
Rehab potential
What is the first visit after admission and who does it?
1st Visit After Admission: 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
What is the scheduled visit and who does it?
Scheduled Visits:
Should occur every 30 days for the 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 is the acute visit and what does it include? Who does it?
Acute: illness or changes reported by nursing staff
Requires focused HPI (info obtained from variety of sources including resident, staff, family), exam, and treatment plan
What is the monthly visit and what does it include? Who does it?
Monthly visit:
Detailed assessment of resident’s current problems, including history, physical exam, chart review, staff interview, observation of care, documentation of visit, consent for care, and communication of treatment plan
What are resident rights in the NH?
Access to health care including selection of medical provider
Privacy – visit should not occur in hallway or other public area; HIPPA
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, treatment plan, referrals
These visits should be no different from how patients are evaluated in the office setting in terms of quality and level of professionalism.
