Caring for older adults with complex health needs: research has shown that gerontology nurse practitioners can halve hospital admission rates and emergency department visits among high needs older adults.

MANAGING FRAIL older adults in the community, while working at the interface between primary and secondary care, is where nurse practitioner (NP) Michal Boyd wants to use her skills. She believes NPs with specialist gerontology skills can make a huge difference to the care of frail older people, reducing hospital admission rates in many instances by half.

"Older adults make up approximately ten percent of people using hospital services. However, their care accounts for about 70 percent of total health care costs," she said. "After a year working as an NP specialising in the care of frail older adults in Colorado, I was able to show an approximately 50 percent drop in hospital admissions and having of the numbers of emergency department visits. Physician visits also decreased by about one third. I know this model works very effectively, both in terms of patient care and costs."

Boyd was approved by the Nursing Council as an NP in aged primary health care last July, one of ten NPs now qualified in New Zealand and the first to work in aged care. She had already qualified as an NP with prescribing rights in the United States, working for many years with high-needs older people in hospitals and the community. As well as working in a clinic setting, she held a joint appointment in the University of Colorado's nursing department, working in a similar way to her present role in New Zealand. Since immigrating to New Zealand in 2002, she has worked as a senior lecturer in the Auckland University of Technology's (AUT) clinically focused masters programme, and, since March this year, has been working with high-needs older adults through Waitemata District Health Board's (DHB) Home and Older Adult Services.

"I now spend about 60 percent of my time with the DHB and 40 percent with AUT. I like the stimulation of combining clinical work with academic teaching, but it is a huge challenge to keep these two demands in balance. Once I complete my practicum experience, I will also have prescribing rights in aged care here. It is appropriate to redo this work, as the medications used here are different from those used in the States."

Last month, Boyd was a keynote speaker at the New Zealand Association of Gerontology conference in Christchurch--Expanding Horizons: The art and science of ageing--attended by over 300 people. She appreciated being able to address health professionals from a range of disciplines on the role of gerontology NPs. "Caring for frail older people in the community usually involves many health professionals. To undertake an assessment, there can be ten different people involved, from physicians to district nurses, outreach nurses, rehabilitation assessors and people from the voluntary sector. The danger is that services can be duplicated and gaps can occur. The key is good co-ordination, a role that an NP can fill superbly well.

"When I assess an older person, I might spend an hour or two with them. I can manage their symptoms and medication, taking into account a whole range of factors like functional, social, financial and mental health issues. This one-on-one care, comprehensive geriatric assessment and care co-ordination can make a huge difference to the life of a frail older person."

Boyd stresses that as an NP, she practises both autonomously and in collaboration with the inter-professional team, providing a wide range of assessment and treatment interventions. As a nurse prescriber, she will need to gain the trust of the doctor involved in the care of the older person, collaborating closely with other health professionals on treatment management.

"Having prescribing rights is just one of many skills an NP uses in the care of older people. However, international research has shown that prescribing knowledge greatly enhances the NP's effectiveness in assessing older persons' medications, interactions and side effects, and in being able to provide timely intervention when necessary. A study in 2002 showed older adult clients with complex needs were prescribed an average of 13 medications. However, there was only a 57 percent concurrence between the GP or practice nurse list and what was actually in the older person's house. (1) Nurse prescribers have also been shown to be very safe." (2,3)

In presenting her case for the place of NPs in aged care at the gerontology conference, Boyd discussed population trends expected over the next few decades. "By 2030, those over 65 are expected to double, making up 22 percent of all New Zealanders. Frail older adults are staying in their homes longer, so when they are admitted to long-term care, they have an increased level of disability and illness. Since 1996/97, hospitalisations have increased 2.1 percent on average each year for people 65 years and older. As the population ages, there are more people with more complex illnesses needing to be cared for in both hospitals and in the community. Not all older adults need intensive follow-up by an NP. The NP would focus on working with high-risk people with complex needs--ie, between two and five percent of older people. It is important the entire continuum of care for older adults is addressed in a co-ordinated way. GPs' and practice nurses' work should focus primarily on keeping elderly people from entering that high-risk category, while geriatric nurse specialists and gerontology NPs work with the multi-disciplinary team with older adults assessed as having higher needs. Basically, there's a lot of work for all of us in aged care to."

Boyd believes it is imperative nurses and NPs present visible outcomes from the work they do with patients. "Nurses in New Zealand are doing chronic illness care, but outcomes and visibility are desperately needed. We must tell people what we do and show that our work makes a difference to patient outcomes. These outcomes are imperative in order to get the necessary funding from DHBs or primary health organisations (PHOs) to support the programmes that are needed and that we can deliver.

"I see a real place for NPs working in residential aged care. One NP could work at two or three facilities. The NP would assess the health status of older adults living in the residential institution, manage that person's care, act as the liaison person for the family, facility and health care team, and provide education and mentoring for nurses and caregivers to improve older adult assessment and care. This would be on-site primary care. The NP's goal would not focus on providing a cure for long-term illnesses, but on maintaining the person's quality of life."

Despite the obvious need, few NPs were identifying this scope of practice, Boyd said. The best strategy was for employers to implement a gerontology nurse specialist role and then provide support for that specialist to complete her clinical masters and submit her portfolio to the Nursing Council.

"At present there is no funding for NPs in GP practices and residential aged care. Nurses need to work within PHOs to secure population-based funding to provide NP specialist care in primary care. They also need to work with DHBs to create a role that works at the interface between primary care and residential aged care and secondary care. At the same time, nurses need to collaborate with academic institutions to help evaluate the effectiveness of NPs and specialist geriatric nurses."

Case Study: Enhancing Mrs A's health and wellbeing

A PRACTICE nurse from a GP's surgery makes a referral to the gerontology nurse practitioner (NP) about an 85-year-old older adult woman living alone in the community. The practice nurse and GP are concerned about Mrs A. because she seems very confused about her medications and has been seen by accident and emergency four times in the last year. She suffers from heart failure and has osteoporosis. Her daughter lives in town, but works full-time and has a family with three teenage children. Mrs A is very frail and at risk of falling, particularly when she showers and dresses in the morning.

The NP visits Mrs A in her home following the referral. The NP completes a comprehensive gerontology assessment, identifying a number of areas of concern. The list of medications sent through from the surgery is very different from the medications found in Mrs A's home and Mrs A is quite confused about them. The physical examination shows Mrs A has compromised respiratory function, oedematous feet and she can only walk four metres before becoming winded. She is also experiencing a heart rate of 50 beats per minute, a significant bradycardia. Mrs A is very confused about what her heart failure really means and what symptoms to watch for. She is on a beta blocker, but the NP finds she is taking twice the scheduled dose, which would most likely account for new bradycardia findings.

The NP identifies several deficits in a functional assessment. Neighbours also look after her, but if Mrs A were to fall, she would have difficulty getting to a phone. Her daughter helps organise her finances--Mrs A is on a small superannuation--and buys her groceries.

The NP calls the GP and provides an overview of the comprehensive geriatric assessment, arranging for Mrs A to have an electrocardiograph and to work with the GP on the correct medications and doses Mrs A should be taking. This includes decreasing the beta blocker and increasing the diuretic dose.

The NP continues to visit Mrs A weekly for the next four weeks. Mrs A's main goal is to stay in her home and to continue to care for her much loved cat. The NP helps communicate with the needs assessment and service co-ordinator about the introduction of home services for help with showering. She also works with the occupational therapist and physiotherapist about other strategies to enhance activities of daily living and strategies to prevent falls.

A multi-disciplinary team meeting takes place. The NP writes up the discussions and plans from this meeting for Mrs A and her daughter, and sends a copy to all team members. The NP talks at length with Mrs A's daughter about her needs as a caregiver and, with Mrs A's permission, shares the plan of care. The NP discusses the signs and symptoms of heart failure exacerbation with Mrs A and her daughter, and an action plan is devised to help them know what to do if the symptoms get worse. Mrs A readily calls the NP if she has questions or concerns, now they have an established relationship. The NP will make further home visits if symptoms get worse and will work closely with the GP on medical intervention.

The goal is to provide Mrs A with more ability to care for herself with the support she needs, so she can realise her goal of staying in her home caring fur her cat as long as is practical.

REFERENCES

(1) Calveley, J. and Mahoney, F. (2002) A patient centred model for integrating primary and secondary services for other people, kaumatua and kuia with multiple and complex needs. Integration Task Force. Auckland Healthcare and ProCare Health Limited: New Zealand.

(2) Mundinger, M. O., Kane, R.L. et al. (2000) Primary care outcomes in patients treated by nurse practitioners or physicians. Journal of the American Medical Association; 283: 1.

(3) Venning, P., Durie, A., Roland, M., Roberts, C., Leese, B. (2000) Randomised controlled trial comparing cost effectiveness of general pracititoners and nurse practitioners in primary care. British Medical Journal; 320, 1021-1.