Advanced practice nurses.

These days, their welcome is becoming ever-warmer

As nurses who choose to work in long-term care settings, we have a front row view of the transition of the traditional nursing home into a virtual hub for a range of services for a diverse population. These days, it's not uncommon to be asked to care for a resident with end-stage Alzheimer's disease in one room and a patient awaiting home-going instructions after hip replacement in another. Many nursing home administrators and DONs are finding that they need nurses with expertise beyond the RN level to coordinate the care for such a heterogeneous mix of residents and patients. Today, having a geriatric nurse practitioner (GNP) or clinical nurse specialist (CNS) on staff is fast becoming less a luxury, and more a necessity. Whether the supply will meet the demand remains to be seen, however. When I received my master's degree in nursing in 1983, I was one of two graduates specializing in geriatrics. The number of master's and doctoral candidates in nursing who are choosing to specialize in geriatrics today is growing - albeit slowly - as the number of elderly patients in all health care settings increases.

As interest grows, the distinctions between the two specialities have begun to blur. Until recently, the clinical nurse specialist was trained to serve more as a consultant or clinical resource for staff education, while the nurse practitioner received more intensive training in direct patient care (primarily in the areas of clinical assessment and pharmacology). In most graduate nursing programs, the trend is now toward programs that simply offer "advanced practice nursing" degrees.

The graduates of those programs have a great deal to offer in the traditional long-term care arena.

Chronic Care

In traditional chronic care, the GNP is the front line of defense against chronic conditions becoming acute episodes that require hospitalization. Unlike a charge nurse, who may be an RN or LPN, and typically has a very large patient load, the nurse practitioner has both the training and the time to recognize subtle, and sometimes atypical, signs of a resident's worsening condition. For example, in our facility, one resident actually leans to the right when he's developing an infection. It's unlikely that a nurse whose duties include passing medications, scheduling, administration, etc, would have the time (or the training) to perform clinical assessments sufficiently thorough to recognize such a subtle, unusual sign.

Because the GNP is qualified to initiate treatment and, in most states, has at least some degree of prescriptive authority, intervention can begin at the earliest signs of worsening health. In facilities without a GNP, treatment often has to wait while the charge nurse tracks down the physician, waits for the return call, brings the physician up to date over the phone and waits for treatment decisions.

The GNP is also available to staff for formal and informal education, and is almost always more readily available and accessible to the residents and their families than are the attending physicians or medical directors. This gives them the opportunity to discuss the plan of care in depth with family members and to address sensitive issues, such as end of life decisions and advance directives.

Higher Acuity

In higher-acuity settings, such as subacute and special care units, the advanced practice nurse (APN) coordinates care among all of the disciplines and provides specialized staff education on a formal and informal basis. On subacute units, the APN serves as a clinical specialist; teaches staff; assesses patients; provides home-going patient education; and consults with physicians and staff on patient care. In this way, the APN often ends up "filling in" for physicians who are on-site only intermittently.

In special care units, the APN's expertise in dealing with both physical and behavioral problems can help reduce the burnout and turnover that often comes from increased demands on the nursing staff assigned to these units.

The APN'S intensive training in patient evaluation and treatment apply to both higher acuity and the more traditionally seen chronic care cases, since patients on a subacute or special care unit still develop urinary tract infections, pneumonia, pressure sores and other conditions, in addition to their primary diagnoses.

Future Challenges Remain

As community-based services delay or avert the need for nursing home placement, APNs will increasingly be lending their skills to areas such as home health care, respite care, outpatient rehabilitation and assisted living. Whatever the setting, however, it is important to remember that changes in reimbursement and prescriptive authority will be needed for the LTC industry to take full advantage of the APN's professional training and experience.

Forty-nine states provide Medicaid reimbursement for APNs and in approximately 34 states, APNs receive third-party reimbursement for at least some services. The rules and rates of reimbursement vary from state to state, and the variations among private insurance companies are even greater, with some denying reimbursement outright.

Prescriptive authority suffers from the same lack of consistency. While most states allow nurse practitioners to prescribe, the degree of prescriptive authority varies from full authority (usually in more rural areas where access to a physician is limited), to authority for all medications except controlled substances, to a requirement that physicians co-sign orders within a predetermined time period, to prescriptive authority by protocol (ie, drugs designated for use for specific conditions).

More consistently applied policies in both areas will benefit not only the APNs themselves, but will also better serve their professional colleagues and, most importantly, the people they care for.

Connie Lokos, MS, RN, GNP-C, is Geriatric Nurse Practitioner, Edward Hines, Jr. VA Hospital, Extended Care Center, Hines, IL.