The role of the gerentological nurse practitioner in nursing homes.
In today's dynamic health care environment, all health care providers must use their resources creatively to remain competitive. One strategy that has been successfully implemented in a steadily increasing number of nursing homes is the use of nurse practitioners to improve quality of care. Nurse practitioners are defined as "professional nurses with advanced education preparation who provide a full range of primary care services within the framework of established professional standards. In addition to providing health promotion and disease prevention services, nurse practitioners assess, diagnosis and manage acute and chronic illnesses, including prescription of pharmacologic and non-pharmacologic therapeutic modalities, in a variety of settings" (NANP, 1993).
As applied specifically to nursing home care, a nurse practitioner may be prepared by education and experience to focus on a particular age group such as older persons (the gerontological nurse practitioner) or on the life span (the family nurse practitioner). "Gerontological" is the term preferred to "geriatric," since it is more descriptive of the primary care focus of the nurse practitioner, as opposed to a disease focus. As a primary care provider, the gerontological nurse practitioner (GNP) is the initial and ongoing contact who promotes the optimal health of a resident, manages acute minor illnesses and stable chronic diseases, and coordinates the interdisciplinary care team and specialists, as necessary.
The development of the GNP role in nursing homes was stimulated in the 1970s by a Mountain States Health Care Corporation's project funded by the Kellogg Foundation. The nurses were prepared in certificate-granting GNP programs at selected universities. The results of this project demonstrated the positive impact GNPs had on resident care when the role was fully developed.
The education of GNPs is now mostly at the graduate level, since the national certifying examination for GNPs has required a masters degree since 1992. With the movement of GNP education to the graduate level little difference has been found between the preparation of the gerontological clinical nurse specialist (CNS) and the GNP and between their roles in the nursing home. Increasingly, both are being referred to as "advanced practice nurses."
The development of the GNP role and its success in the nursing home depends on developing, at the start, a mutual understanding among the administrator, the director of nursing, the medical director and the nurse practitioner. Particularly with respect to the DON, the skills and contributions of the GNP should be defined clearly, and the GNP's potential value as a resource for the nursing staff should be underscored.
In defining the GNP's position in the caregiving spectrum, it is helpful to understand how their role description has evolved. Initially GNPs were viewed more as "physician extenders," the provider of on-site medical care in view of the relatively few hours physicians spend in nursing homes. Under this label, they have frequently been employed by physicians or by medical directors to cover their patients in one or more nursing homes.
However, nurses have viewed GNPs as "nursing expanders," since they extend beyond the traditional scope of nursing practice to meet common medical needs of residents. Nurse expanders work for the nursing service and identify more with the goals and holistic approach of a nursing model. Frequently, in small homes, the GNP is also the DON. Both the "physician extender" and "nurse expander" views are valid for the GNP, since she integrates the medical with the nursing model of care.
In order to avoid the conflict of serving "two masters," however, the GNP should report directly to the administrator, who should solicit input on the GNP's position description and evaluation from both the medical directors and the DON. This integrated model of the GNP is most responsive to nursing home residents' needs and the goals of the institution.
An American College of Health Care Administrators report, "Efficacy of the Use of Physician Extenders in Nursing Homes" (ACHCA, 1989), cited the following benefits from the use of "physician extenders" (i.e., nurse practitioners and physicians' assistants):
1. Increased accessibility/efficiency. The GNP is available on a continuing basis and establishes a rapport with the residents, families, nursing and support staff, and medical staff. This facilitates communication and ultimately efficiency in providing care and meeting common goals.
2. Availability to attend to minor problems. With advanced assessment and diagnostic skills, the GNP improves care through timely assessment, diagnosis, intervention or referral, and evaluation of subtle health status changes.
3. Cost containment. Preventing or minimizing unnecessary physician visits, transfers to the emergency room, and acute hospital stays saves money. This will be of greater importance as nursing homes' ability to shift costs among payers is reduced by the adoption of capitation and other forms of prospective payment.
4. Increased health education and counseling. By being available to residents and families for counseling and teaching about their health status, health improvement strategies and self-care abilities, the GNP empowers them to take an active role in their health and care. Meanwhile, instructing nursing and other support staff in current skills and knowledge will help these staffers to be more effective care providers. Providing clinical experiences for undergraduate and graduate nursing students and for medical students and residents is also an important contribution GNPs make to improving the care of older persons.
5. Increased quality of care. This should be an ongoing goal of all care providers. GNPs can be a multidisciplinary resource: to nursing, which is responsible for 24 hour-a-day care; to physicians, who are responsible for medical care but who spend limited time with the resident; to those who pay for care and are interested in cost containment and cost-effectiveness; and ultimately to the residents and their families, who both experience and pass judgement on the outcomes of the care provided.
6. Increased resident and family satisfaction. Resident and families feel more secure and satisfied when they can easily call upon one provider who is knowledgeable about the resident's health status and total care plan.
In addition to those benefits cited by ACHCA, GNPs can provide continuity of care through case management. Increasingly, nursing homes are not the "last home" but are providing episodic care interspersed with a full range of community services, such as home care, respite care, rehabilitation, and subacute care. The GNP is in a position to ensure that the resident is in the most appropriate and cost-effective level of care required by health status and, further, that the care can be justified for reimbursement.
The ACHCA document also identified common hindrances to implementing the physician extender role:
1. Medicare and Medicaid reimbursement. The Omnibus Budget Reconciliation Act (OBRA) of 1989 authorizes Part B Medicare coverage of services that are legally performed by a nurse practitioner (NP) that would otherwise be provided by a physician or are "incident to" a physician's service. Payment is made to the employer of the NP. OBRA 1990, effective 1991, extended direct reimbursement to NPs in rural areas in accordance with a statutory formula. OBRA regulations also gave states the option of allowing NPs to supervise the health care of residents in nursing facilities. However, the "incident to" phrase has lead to a variety of interpretations by the fiscal intermediaries. Even though clarification of the language has been issued by the Health Care Financing Administration (HCFA), Medicare and Medicaid reimbursement continues to be confusing. Attempting to sort out the various interpretations is not within the scope of this article.
2. Fear of malpractice litigation. In fact, malpractice litigation is at a very low rate for NPs and particularly for GNPs, as indicated by the low insurance premiums for GNPs -- approximately $200-$300 per year.
3. Regulatory constraints (prescribing, supervision, and countersigning). The status of regulatory constraints varies according to the state. Forty-five states, including the District of Columbia, now have some form of NP prescriptive authority. Sixteen states have no requirements for physician supervision of NPs. Twenty-four states have a requirement for some physician collaboration on supervision.
The successful implementation of the GNP role in the nursing home depends on the institution's goals, the GNP's position description and the facility's organizational structure and planning. The viability of the position depends not only on regulatory and reimbursement criteria, but also on the acceptance of the GNP by the residents and families, nursing staff, and medical staff. These various challenges are worth addressing, because employment of a GNP is a cost-effective way to improve nursing home quality of care.
Foundation of American College of Health Care Administrators. (1989). Efficacy of the use of physician extenders in nursing homes. Alexandria, VA: ACHCA.
Health Care Financing Administration. (1992), "Nonphysician Health Care Practitioners under the Medicare and Medicaid Program". Washington, DC.: USDHHS.
National Alliance of Nurse Practitioners, (1993). "The Definition of a Nurse Practitioner". Washington, DC: NANP.
Norma R. Small, C.R.N.P., Ph.D., is former President of the National Conference of Gerontological Nurse Practitioners. She is current Chairperson of The National Alliance of Nurse Practitioners.
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|Title Annotation:||Nursing Care|
|Author:||Small, Norma R.|
|Date:||May 1, 1994|
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