Ready to Work With a Nurse Practitioner?

Abstract

DR. NICHOLS is the vice president for medical services of the Cabrini Eldercare Consortium in New York City, which includes two skilled nursing facilities, three home care agencies, two adult day care programs, and a senior housing complex. He invites your questions for possible discussion in this column. Please submit them by e-mail to [email protected].Dear Dr. Jeff:We have no experience working with nurse practitioners. An attending physician at our facility wants a nurse practitioner to see his patients when he is unavailable. What concerns, if any, should we have?Dr. Jeff responds: The role of nurse practitioner (NP) dates back to 1965, but over the past 15 years, NPs have moved from being rare to commonplace in long-term care.Multiple studies have demonstrated that the service they provide is acceptable to patients and families. Quality studies suggest that the care is as good as or better than that provided by the average primary care physician.Indeed, Evercare is a managed-care product that uses NPs extensively to decrease hospitalizations of long-term care residents. UnitedHealthcare, which owns Evercare, has marketed this approach in many states with apparent success and profitability.I have collaborated with NPs in home care and nursing home care since 1986. Some of them have been superb clinicians, and most have been delightful, caring, and compassionate professionals.AMDA, the American Medical Association, the American College of Physicians, and the American Academy of Family Physicians all support collaboration between physicians and NPs—with the physician in a supervisory role.NPs usually possess a skill set that differs from that of a typical physician. It comes from their initial nursing training combined with additional training in diagnosis and disease management. For example, nursing training provides much greater emphasis and superior experience in patient and family education.But nurses without NP training are often limited in their ability to explain the justification for various diagnostic tests or treatments. Residents and families in long-term care frequently complain that they receive inadequate explanations of diagnoses and medications, even when the physician believes that the patient has been fully informed.Superior patient-education skills are a major explanation for the ready acceptance of NPs by patients and families. Wound care plays a minimal role in standard medical education, while nursing training and bedside experience provide extensive experience in wound evaluation and management. This background may be useful in the management of pressure ulcers or surgical wounds in the nursing home, allowing the NP to respond to a changing wound with an immediate order for a new treatment plan.Nursing education programs provide extensive training in the recognition of the social and emotional impacts of disease and disability, areas in which medical training programs are sadly deficient. The NP can order a consultation from a mental health professional when appropriate.There's Always a CaveatNevertheless, there is a variety of concerns that your facility should address prior to adding an NP to your medical staff. First is that there are federal regulations that strictly delineate the services and functions that only a licensed physician may provide.Among these, only a physician can serve as the primary attending for a patient. This responsibility may be shared with a collaborating practitioner, such as an NP, but cannot simply be delegated. From a legal (and liability) viewpoint the physician is always responsible. Also, only a physician can make the initial comprehensive admission visit required to establish the plan of care (although an NP could see a patient for a particular problem prior to this “initial” visit).Various services can be ordered only by a physician, including certification of the medical necessity for Medicare extended-care services and ordering Medicare-reimbursable rehabilitation services, reimbursable durable medical equipment, and Medicare home-care services after discharge. Although an NP can make federally mandated visits, it can be only every other visit, alternating with a physician.When your attending physician suggests that the NP will see patients “when he is unavailable,” he may not be thinking about many of these limitations. A significant degree of physician availability is still required, and this should be made explicit before you accept the NP's role—and this requirement should be made an official policy of the nursing home. An article in the November 2008 issue of Caring for the Ages reviewed these federal requirements (www.caringfortheages.com/article/S1526-4114(08)60293-0/fulltext).Second, the facility should be aware that the scope of practice for NPs is established by individual states through their nursing-practice acts, and that legislatures are notorious for periodically changing these laws.For example, New York State requires a written “Collaborative Practice Agreement” between the NP and a licensed physician, which must be filed with the state within a set time after the collaboration begins and that spells out which textbooks or protocols will be used as care standards and what procedures will be followed if the physician and NP disagree on the proper care of a patient.In New York, no physician can collaborate with more than five NPs, but the physician need not be physically present or even immediately available for the NP to perform any medical service that a licensed physician might otherwise do, from psychotherapy to a cholecystectomy.You should certainly check with your state AMDA affiliate and other appropriate state organizations to ensure that you will be compliant with all state regulations. And you must confirm that the NP has malpractice insurance appropriate for a practitioner rather than simply a nursing malpractice policy.Within Your FacilityI would strongly recommend a discussion with your director of nursing prior to any decision regarding the NP and an interview between the DON and any prospective NP for the facility.Under the best of circumstances, the nursing department and floor nurses see the NP as an ally, someone who understands and respects their expertise but with the power of the pen and order book. Under the worst of circumstances, the NP can be seen as a peer who refuses to do his or her share (“she just walked away when I asked her to change a dressing”) or even an upstart trying to give the nurses orders although he or she is not a “real” physician.If your nursing staff hasn't worked with an NP before, it is important that the NPs role be understood and accepted before any major misunderstanding occurs.You should also do the same standard professional review that you would do for any other practitioner who might join your medical staff. Simply because Dr. X has chosen to employ someone is no reason to automatically accept the person into your facility.Although the overwhelming majority of NPs are decent, hardworking professionals, some have offered fraudulent credentials, suffer from substance abuse, are barred from Medicare or Medicaid, have committed elder abuse, or can just be obnoxious. Community physicians, in my experience, rarely review credentials with sufficient paranoia and are usually unaware of available resources to confirm an employee's background and experience.The facility must exercise due diligence. Also, the medical director and the administrator should meet with the prospective NP to confirm that no major personality clash is likely to occur.During the review of credentials and the interview process, you should try to assess the NP's level of knowledge and experience in geriatrics and nursing home care. NP training generally leads to certification in an area such as pediatrics, family medicine, adult medicine, or geriatrics. As in medicine, certification is the responsibility of nursing organizations.The Gerontological Advanced Practice Nurses Association has 16 chapters across the country, but the majority of NPs have not selected geriatrics as their specialty area. Those who are not geriatric nurse practitioners (GNPs) may have very little training in the needs and problems of frail seniors in nursing homes (putting the non-GNPs on the same level as most graduates of internal medicine training programs).You should not assume that an NP with many years of experience necessarily has the knowledge of nursing home issues, much less code requirements, that an experienced floor nurse in your facility might take for granted. The NP might have years of long-term care experience but still require an orientation to your special environment.Some physicians have become defensive regarding the role of NPs in long-term care, partly in reaction to some grandiose proposals to staff up nursing homes with NPs.In a country experiencing a serious nursing shortage and an even more severe shortage of professors to train nurses, the vision of giant armies of GNPs marching into nursing homes is absurd. The recent Institute of Medicine study of the need for trained professionals to care for an aging population identified severe shortages across the board. We should welcome everyone prepared to share in the care of our frail residents. DR. NICHOLS is the vice president for medical services of the Cabrini Eldercare Consortium in New York City, which includes two skilled nursing facilities, three home care agencies, two adult day care programs, and a senior housing complex. He invites your questions for possible discussion in this column. Please submit them by e-mail to [email protected]. Dear Dr. Jeff: We have no experience working with nurse practitioners. An attending physician at our facility wants a nurse practitioner to see his patients when he is unavailable. What concerns, if any, should we have? Dr. Jeff responds: The role of nurse practitioner (NP) dates back to 1965, but over the past 15 years, NPs have moved from being rare to commonplace in long-term care. Multiple studies have demonstrated that the service they provide is acceptable to patients and families. Quality studies suggest that the care is as good as or better than that provided by the average primary care physician. Indeed, Evercare is a managed-care product that uses NPs extensively to decrease hospitalizations of long-term care residents. UnitedHealthcare, which owns Evercare, has marketed this approach in many states with apparent success and profitability. I have collaborated with NPs in home care and nursing home care since 1986. Some of them have been superb clinicians, and most have been delightful, caring, and compassionate professionals. AMDA, the American Medical Association, the American College of Physicians, and the American Academy of Family Physicians all support collaboration between physicians and NPs—with the physician in a supervisory role. NPs usually possess a skill set that differs from that of a typical physician. It comes from their initial nursing training combined with additional training in diagnosis and disease management. For example, nursing training provides much greater emphasis and superior experience in patient and family education. But nurses without NP training are often limited in their ability to explain the justification for various diagnostic tests or treatments. Residents and families in long-term care frequently complain that they receive inadequate explanations of diagnoses and medications, even when the physician believes that the patient has been fully informed. Superior patient-education skills are a major explanation for the ready acceptance of NPs by patients and families. Wound care plays a minimal role in standard medical education, while nursing training and bedside experience provide extensive experience in wound evaluation and management. This background may be useful in the management of pressure ulcers or surgical wounds in the nursing home, allowing the NP to respond to a changing wound with an immediate order for a new treatment plan. Nursing education programs provide extensive training in the recognition of the social and emotional impacts of disease and disability, areas in which medical training programs are sadly deficient. The NP can order a consultation from a mental health professional when appropriate. There's Always a CaveatNevertheless, there is a variety of concerns that your facility should address prior to adding an NP to your medical staff. First is that there are federal regulations that strictly delineate the services and functions that only a licensed physician may provide.Among these, only a physician can serve as the primary attending for a patient. This responsibility may be shared with a collaborating practitioner, such as an NP, but cannot simply be delegated. From a legal (and liability) viewpoint the physician is always responsible. Also, only a physician can make the initial comprehensive admission visit required to establish the plan of care (although an NP could see a patient for a particular problem prior to this “initial” visit).Various services can be ordered only by a physician, including certification of the medical necessity for Medicare extended-care services and ordering Medicare-reimbursable rehabilitation services, reimbursable durable medical equipment, and Medicare home-care services after discharge. Although an NP can make federally mandated visits, it can be only every other visit, alternating with a physician.When your attending physician suggests that the NP will see patients “when he is unavailable,” he may not be thinking about many of these limitations. A significant degree of physician availability is still required, and this should be made explicit before you accept the NP's role—and this requirement should be made an official policy of the nursing home. An article in the November 2008 issue of Caring for the Ages reviewed these federal requirements (www.caringfortheages.com/article/S1526-4114(08)60293-0/fulltext).Second, the facility should be aware that the scope of practice for NPs is established by individual states through their nursing-practice acts, and that legislatures are notorious for periodically changing these laws.For example, New York State requires a written “Collaborative Practice Agreement” between the NP and a licensed physician, which must be filed with the state within a set time after the collaboration begins and that spells out which textbooks or protocols will be used as care standards and what procedures will be followed if the physician and NP disagree on the proper care of a patient.In New York, no physician can collaborate with more than five NPs, but the physician need not be physically present or even immediately available for the NP to perform any medical service that a licensed physician might otherwise do, from psychotherapy to a cholecystectomy.You should certainly check with your state AMDA affiliate and other appropriate state organizations to ensure that you will be compliant with all state regulations. And you must confirm that the NP has malpractice insurance appropriate for a practitioner rather than simply a nursing malpractice policy. Nevertheless, there is a variety of concerns that your facility should address prior to adding an NP to your medical staff. First is that there are federal regulations that strictly delineate the services and functions that only a licensed physician may provide. Among these, only a physician can serve as the primary attending for a patient. This responsibility may be shared with a collaborating practitioner, such as an NP, but cannot simply be delegated. From a legal (and liability) viewpoint the physician is always responsible. Also, only a physician can make the initial comprehensive admission visit required to establish the plan of care (although an NP could see a patient for a particular problem prior to this “initial” visit). Various services can be ordered only by a physician, including certification of the medical necessity for Medicare extended-care services and ordering Medicare-reimbursable rehabilitation services, reimbursable durable medical equipment, and Medicare home-care services after discharge. Although an NP can make federally mandated visits, it can be only every other visit, alternating with a physician. When your attending physician suggests that the NP will see patients “when he is unavailable,” he may not be thinking about many of these limitations. A significant degree of physician availability is still required, and this should be made explicit before you accept the NP's role—and this requirement should be made an official policy of the nursing home. An article in the November 2008 issue of Caring for the Ages reviewed these federal requirements (www.caringfortheages.com/article/S1526-4114(08)60293-0/fulltext). Second, the facility should be aware that the scope of practice for NPs is established by individual states through their nursing-practice acts, and that legislatures are notorious for periodically changing these laws. For example, New York State requires a written “Collaborative Practice Agreement” between the NP and a licensed physician, which must be filed with the state within a set time after the collaboration begins and that spells out which textbooks or protocols will be used as care standards and what procedures will be followed if the physician and NP disagree on the proper care of a patient. In New York, no physician can collaborate with more than five NPs, but the physician need not be physically present or even immediately available for the NP to perform any medical service that a licensed physician might otherwise do, from psychotherapy to a cholecystectomy. You should certainly check with your state AMDA affiliate and other appropriate state organizations to ensure that you will be compliant with all state regulations. And you must confirm that the NP has malpractice insurance appropriate for a practitioner rather than simply a nursing malpractice policy. Within Your FacilityI would strongly recommend a discussion with your director of nursing prior to any decision regarding the NP and an interview between the DON and any prospective NP for the facility.Under the best of circumstances, the nursing department and floor nurses see the NP as an ally, someone who understands and respects their expertise but with the power of the pen and order book. Under the worst of circumstances, the NP can be seen as a peer who refuses to do his or her share (“she just walked away when I asked her to change a dressing”) or even an upstart trying to give the nurses orders although he or she is not a “real” physician.If your nursing staff hasn't worked with an NP before, it is important that the NPs role be understood and accepted before any major misunderstanding occurs.You should also do the same standard professional review that you would do for any other practitioner who might join your medical staff. Simply because Dr. X has chosen to employ someone is no reason to automatically accept the person into your facility.Although the overwhelming majority of NPs are decent, hardworking professionals, some have offered fraudulent credentials, suffer from substance abuse, are barred from Medicare or Medicaid, have committed elder abuse, or can just be obnoxious. Community physicians, in my experience, rarely review credentials with sufficient paranoia and are usually unaware of available resources to confirm an employee's background and experience.The facility must exercise due diligence. Also, the medical director and the administrator should meet with the prospective NP to confirm that no major personality clash is likely to occur.During the review of credentials and the interview process, you should try to assess the NP's level of knowledge and experience in geriatrics and nursing home care. NP training generally leads to certification in an area such as pediatrics, family medicine, adult medicine, or geriatrics. As in medicine, certification is the responsibility of nursing organizations.The Gerontological Advanced Practice Nurses Association has 16 chapters across the country, but the majority of NPs have not selected geriatrics as their specialty area. Those who are not geriatric nurse practitioners (GNPs) may have very little training in the needs and problems of frail seniors in nursing homes (putting the non-GNPs on the same level as most graduates of internal medicine training programs).You should not assume that an NP with many years of experience necessarily has the knowledge of nursing home issues, much less code requirements, that an experienced floor nurse in your facility might take for granted. The NP might have years of long-term care experience but still require an orientation to your special environment.Some physicians have become defensive regarding the role of NPs in long-term care, partly in reaction to some grandiose proposals to staff up nursing homes with NPs.In a country experiencing a serious nursing shortage and an even more severe shortage of professors to train nurses, the vision of giant armies of GNPs marching into nursing homes is absurd. The recent Institute of Medicine study of the need for trained professionals to care for an aging population identified severe shortages across the board. We should welcome everyone prepared to share in the care of our frail residents. I would strongly recommend a discussion with your director of nursing prior to any decision regarding the NP and an interview between the DON and any prospective NP for the facility. Under the best of circumstances, the nursing department and floor nurses see the NP as an ally, someone who understands and respects their expertise but with the power of the pen and order book. Under the worst of circumstances, the NP can be seen as a peer who refuses to do his or her share (“she just walked away when I asked her to change a dressing”) or even an upstart trying to give the nurses orders although he or she is not a “real” physician. If your nursing staff hasn't worked with an NP before, it is important that the NPs role be understood and accepted before any major misunderstanding occurs. You should also do the same standard professional review that you would do for any other practitioner who might join your medical staff. Simply because Dr. X has chosen to employ someone is no reason to automatically accept the person into your facility. Although the overwhelming majority of NPs are decent, hardworking professionals, some have offered fraudulent credentials, suffer from substance abuse, are barred from Medicare or Medicaid, have committed elder abuse, or can just be obnoxious. Community physicians, in my experience, rarely review credentials with sufficient paranoia and are usually unaware of available resources to confirm an employee's background and experience. The facility must exercise due diligence. Also, the medical director and the administrator should meet with the prospective NP to confirm that no major personality clash is likely to occur. During the review of credentials and the interview process, you should try to assess the NP's level of knowledge and experience in geriatrics and nursing home care. NP training generally leads to certification in an area such as pediatrics, family medicine, adult medicine, or geriatrics. As in medicine, certification is the responsibility of nursing organizations. The Gerontological Advanced Practice Nurses Association has 16 chapters across the country, but the majority of NPs have not selected geriatrics as their specialty area. Those who are not geriatric nurse practitioners (GNPs) may have very little training in the needs and problems of frail seniors in nursing homes (putting the non-GNPs on the same level as most graduates of internal medicine training programs). You should not assume that an NP with many years of experience necessarily has the knowledge of nursing home issues, much less code requirements, that an experienced floor nurse in your facility might take for granted. The NP might have years of long-term care experience but still require an orientation to your special environment. Some physicians have become defensive regarding the role of NPs in long-term care, partly in reaction to some grandiose proposals to staff up nursing homes with NPs. In a country experiencing a serious nursing shortage and an even more severe shortage of professors to train nurses, the vision of giant armies of GNPs marching into nursing homes is absurd. The recent Institute of Medicine study of the need for trained professionals to care for an aging population identified severe shortages across the board. We should welcome everyone prepared to share in the care of our frail residents.