Nurse Practitioner Services Research Articles

Primary health care services for patients with chronic disease in Newfoundland and Labrador: a descriptive analysis.

Newfoundland and Labrador has a rapidly aging population, much of which is rural, with poor health behaviours and high rates of chronic disease. These factors contribute to a unique challenge in health care delivery. Our aim was to describe the availability of publicly funded primary health care programs and services delivered by regional health authorities across the province. We performed a descriptive analysis using data from a cross-sectional provincial primary health care survey deployed across Newfoundland and Labrador. Survey data included location, disease-specific chronic disease prevention programming, types of routine primary care, allied health prevention and promotion, chronic disease prevention and management services, and team-based care. The mode of service delivery was identified for most programs and services. Surveys were returned by 153 sites (99.4% response rate). Family physician services were available at 66% of sites (95/145) and nurse practitioner services were available at 51% (74/144) of sites. Many sites offered screening for cervical (60%, 86/144), colon (42%, 59/142) and prostate cancers (43%, 60/141), in addition to various self-management and education services. Allied health services, such as clinical nutrition counselling (47%, 68/46) and occupational therapy (46%, 68/147), were available at many sites. Available health care services were most often offered by on-site staff, and few sites provided primary health care services through telehealth. Overall, rural sites offered a greater variety of services than urban sites. Considerable variability exists in the range of primary health care services available across Newfoundland and Labrador, with limited delivery of some programs and services. Future research should examine how availability of programs and services affects health outcomes and costs.

Establishing the nurse practitioner workforce in rural New Zealand: barriers and facilitators

INTRODUCTION The health sector is facing considerable challenges to meet the health needs of rural communities. Nurse practitioners (NPs) deliver primary health care (PHC) services similar to general practitioner (GP) services, within a health equity and social justice paradigm. Despite GP workforce deficits, New Zealand has been slow to effectively utilise NPs. AIM From a larger study exploring the establishment of NP services, this paper reports on the barriers and facilitators to becoming a NP in rural PHC. METHODS Overall, 13 NPs and 4 NP candidates participated in individual or group interviews. Participants were employed in a variety of PHC settings from six district health boards across New Zealand. Using a scaffold map constructed to show the stages of the pathway from nurse to NP, data were analysed to identify experiences and events that facilitated or were barriers to progress. RESULTS Experiences varied considerably between participants. Commitment to the development of the NP role in their local areas, including support, advanced clinical opportunities, supervision, funding and NP job opportunities, were critical to progression and success. Existing GP shortages and the desire to improve health outcomes for communities drove nurses to become NPs. DISCUSSION Implementation of the NP workforce across New Zealand remains ad hoc and inconsistent. While there are pockets of great progress, overall, the health sector has failed to embrace the contribution that NPs can make to PHC service delivery. A national approach is required to develop the NP workforce as a mainstream PHC provider.

Multidisciplinary team attitudes to an advanced nurse practitioner service in an emergency department.

The aim of this study was to examine an emergency department's (ED) multidisciplinary teams' (MDTs) attitudes towards an advanced nurse practitioner (ANP) service. The ED in question is not the author's place of work. A Likert-type questionnaire was used to gain a total attitude score (TAS), which was analysed in relation to participants' gender, age, professional background, level of education and years of experience in the ED, as well as previous and current contact with emergency nurse practitioners and/or ANPs. A total of 115 questionnaires were distributed, and respondents included doctors, nurses, managers, pharmacists, radiographers and a physiotherapist. Participants provided qualitative data to explain their choices, and were asked to describe positive and negative aspects of an ANP service. The data were analysed using a mixed-methods approach. The TASs were generally positive and there were no statistical differences between the professional groups, although there was some resistance from participants. Overall, the MDT believes the ANP service will improve patient care, waiting times, team divisions and patients' experiences in the ED if the roles and responsibilities are clearly defined and communicated. In addition, the service should receive enough funding to ensure its sustainability and appropriate supervision by a senior doctor should be made available.

Characteristics of Nurse Practitioner Practice in Family Health Teams in Ontario, Canada.

Nurse practitioners (NPs) in Ontario work in a number of settings, including physician-led, interprofessional Family Health Teams (FHTs). However, many aspects of NP practice within the FHTs are unknown. Our study aimed to describe the characteristics of NP practice in FHTs and the relationships between NPs and physicians within this model. This cross-sectional descriptive study analyzed NP service and diagnostic code data collected for every NP patient encounter from 2012 to 2015. Encounter data were linked to health administrative data housed at the Institute for Clinical Evaluative Sciences to allow for comparison with physician service and diagnostic codes. Findings demonstrated that NPs saw patients across all age groups for one to more than five problems per encounter and that NPs handled both acute and episodic care and chronic disease management issues. Patients with chronic conditions had more encounters with physicians than with NPs. In addition, compared to physicians, NPs saw more female than male patients. Our findings provide a snapshot of NP practice in FHTs and may be useful in informing other practice models in Ontario, elsewhere in Canada, and internationally. More evidence is needed, however, to clarify the responsibilities of the NPs in collaborative relationships with physicians and to embed policies that will ensure that NPs work to their full potential. In addition, applying service coding to all health care providers in FHTs could enhance data on interprofessional teams and the individual clinicians that comprise them.

Privately practicing nurse practitioner services in Australia and patient access to care: Results from realist interviews.

To facilitate the expansion of nurse practitioners working in community and primary health settings, legislative changes were enacted in 2010. These led to privately practicing nurse practitioners (PPNPs) being enabled to provide care subsidized through the Australian Government Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. Little is known about the impact of this legislation on patient access to care in Australia. To explore how, why and in which contexts PPNP services in Australia impact on patient access to care. Semistructured interviews using realist evaluation were undertaken with 20 participants, selected through stratified sampling using geographic criteria (State/territory in which practicing) and dividing the sample representatively between those who worked solely in private practice and those who worked in both private and public practice. Thematic analysis of qualitative data was undertaken. Findings suggest that PPNPs have increased access to care for patients, predominantly in community and primary health settings. In increasing access to care, PPNPs have the potential to reduce hospital and general practitioner attendance, thereby potentially reducing the ever-increasing demand for health care.

"It's about fitting in with the organisation": A qualitative study of employers of nurse practitioners.

To explore the views of employers about the value nurse practitioners (NPs) add to health services, enablers and barriers to employing NPs, and intentions to employ NPs or expand NP services in the future. Research on Australian NPs has focused on NPs' experiences or patient-related factors like waiting times. Few studies have explored NP roles from the perspective of employers. Australian NPs employed by the private sector are eligible for reimbursement by the national health insurance scheme (Medicare Australia), potentially generating revenue for employers and broadening their career opportunities. We aimed to explore private sector employers' views on the barriers and facilitators to employing NPs and to identify factors affecting NP employability. A qualitative descriptive exploratory study. Employers of NPs from 23 private and nonprofit health services in Western Australia were interviewed. Inductive content analysis was used to explore the data. Enablers to employing an NP included enhanced customer service and improved health outcomes. Barriers to employing an NP included lack of financial benefit and inadequate experience or qualifications. Employers also identified future directions for NP employability, such as filling a gap that added value to the health service. Employers wanted NPs to work towards a shared vision of patient care that aligned with organisational needs. Findings can inform NP education and workforce planning to optimally meet employer and patient health needs.

Determining geographic accessibility of family physician and nurse practitioner services in relation to the distribution of seniors within two Canadian Prairie Provinces

Equitable access and distribution of health care services for rural and remote populations is a substantial challenge for health workforce planners and policy makers. Geospatial examination of access to health care considers both need and supply dimensions together to determine spatial access scores which contribute to a greater understanding of potential inequity in accessibility. This geospatial investigation explores geographic variation in accessibility to primary health care services utilizing combined access scores for family physicians and nurse practitioner services in urban and rural communities in the Canadian Prairie provinces of Saskatchewan and Alberta. An index of access scores was developed using a floating catchment area framework and a census subdivision geographic unit. Information about family physician and nurse practitioner practice locations and spatial population data were obtained from the Canadian Institute for Health Information and Statistics Canada respectively. Alberta has a better overall provincial access score than Saskatchewan for family physicians and nurse practitioners combined (11.37 vs. 9.77). The results demonstrate that nurse practitioner services are likely addressing primary care access gaps due to reduced numbers of family physician services in certain geographical areas. Combined access scores reveal inequalities in the distribution of primary health care services relative to the proportion of population aged 65 + across both provinces, particularly in rural and remote communities. This study contributes to health services research by exploration of combined access scores for family physician and nurse practitioner services in relation to the distribution of seniors. These findings provide insight into which areas may be in need of increased primary health care services with a focus on both of these health professional groups. The findings of this research will serve as a foundational model for future expansion of the methods to other health care provider groups and to other population health need indicators provincially and nationally.

Nursing service innovation: A case study examining emergency nurse practitioner service sustainability.

This research aimed to explore factors that influence sustainability of health service innovation, specifically emergency nurse practitioner service. Planning for cost effective provision of healthcare services is a concern globally. Reform initiatives are implemented often incorporating expanding scope of practice for health professionals and innovative service delivery models. Introducing new models is costly in both human and financial resources and therefore understanding factors influencing sustainability is imperative to viable service provision. This research used case study methodology (Yin, ). Data were collected during 2014 from emergency nurse practitioners, emergency department multidisciplinary team members and documents related to nurse practitioner services. Collection methods included telephone and semi-structured interviews, survey and document analysis. Pattern matching techniques were used to compare findings with study propositions. In this study, emergency nurse practitioner services did not meet factors that support health service sustainability. Multidisciplinary team members were confident that emergency nurse practitioner services were safe and helped to meet population health needs. Organizational support for integration of nurse practitioner services was marginal and led to poor understanding of service capability and underuse. This research provides evidence informing sustainability of nursing service models but more importantly raises questions about this little explored field. The findings highlight poor organizational support, excessive restrictions and underuse of the service. This is in direct contrast to contemporary expanding practice reform initiatives. Organizational support for integration is imperative to future service sustainability.

An advanced nurse practitioner service for neonates, children and young people.

The NHS continues to face unprecedented demands and reform which necessitates a move away from traditional modes of delivery. Over the past ten years economic austerity, changes to legislation and professional career developments have led to healthcare service redesign and innovations in nursing roles, including the development of the advanced nurse practitioner (ANP) role. This article explores how one organisation created an ANP service for out-of-hours neonatal and paediatric care in a district general hospital setting. It was found that ANPs help to provide continuity of care, support learning, inspire continued professional development and lead on healthcare agendas. However, the ANP service faced factors not exclusive to local context including an ageing workforce, difficulties in recruiting and retaining suitably qualified staff and economic pressures. The future of the service depends on it overcoming these factors while demonstrating that the shift from traditional models of care can lead to a positive outcome.

Implementing two nurse practitioner models of service at an Australian male prison: A quality assurance study

To examine the quality and safety of nurse practitioner services of two newly implemented nurse practitioner models of care at a correctional facility. Nurse practitioners could help to meet the physical and mental health needs of Australia's growing prison population; however, the nurse practitioner role has not previously been evaluated in this context. A quality assurance study conducted in an Australian prison where a primary health nurse practitioner and a mental health nurse practitioner were incorporated into an existing primary healthcare service. The study was guided by Donabedian's structure, processes and outcomes framework. Routinely collected information included surveys of staff attitudes to the implementation of the nurse practitioner models (n=21 staff), consultation records describing clinical processes and time use (n=289 consultations), and a patient satisfaction survey (n=29 patients). Data were analysed descriptively and compared to external benchmarks where available. Over the two-month period, the nurse practitioners provided 289 consultations to 208 prisoners. The presenting problems treated indicated that most referrals were appropriate. A significant proportion of consultations involved medication review and management. Both nurse practitioners spent more than half of their time on individual patient-related care. Overall, multidisciplinary team staff agreed that the nurse practitioner services were necessary, safe, met patient need and reduced treatment delays. Findings suggest that the implementation of nurse practitioners into Australian correctional facilities is acceptable and feasible and has the potential to improve prisoners' access to health services. Structural factors (e.g., room availability and limited access to prisoners) may have reduced the efficiency of the nurse practitioners' clinical processes and service implementation. Results suggest that nurse practitioner models can be successfully integrated into a prison setting and could provide a nursing career pathway.

Practice activities of privately-practicing nurse practitioners: Results from an Australian survey.

To facilitate expansion of privately-practicing nurse practitioners in community and primary care settings, a legislative amendment in 2010 made privately-practicing nurse practitioners eligible to provide services subsidised through the Medicare Benefits Schedule and the Pharmaceutical Benefits Scheme. To evaluate their practice activities, a national survey of privately-practicing nurse practitioners in Australia was conducted, and data analysed using descriptive statistics and thematic analysis (n=73). As part of their role, 96% (n=70) participants reported undertaking direct patient care, 95% (n=69) patient education and health promotion, 95% (n=69) prescribed medications, 92% (n=67) referred patients for diagnostic investigations, and 88% (n=64) reported making a diagnosis. Over 50% of participants saw up to 15 patients daily, and 80% (n=58) treated the same patients on a regular basis. Of the participants, 59% (n=43) perceived that they worked to their full scope of practice. The mainstay of privately-practicing nurse practitioner services is provision of direct patient care in community and primary healthcare settings, suggesting they have emerging potential in addressing the ever-increasing demand for healthcare in Australia.

Political Efficacy and Participation of Nurse Practitioners.

Twenty-eight states have laws and regulations limiting the ability of nurse practitioners (NPs) to practice to the full extent of their education and training, thereby preventing patients from fully accessing NP services. Revisions to state laws and regulations require NPs to engage in the political process. Understanding the political engagement of NPs may facilitate the efforts of nurse leaders and nursing organizations to promote change in state rules and regulations. The purpose of this study was to describe the political efficacy and political participation of U.S. NPs and gain insight into factors associated with political interest and engagement. In the fall of 2015, we mailed a survey to 2,020 NPs randomly chosen from the American Academy of Nurse Practitioners' database and 632 responded (31% response rate). Participants completed the Trust in Government (external political efficacy) and the Political Efficacy (internal political efficacy) scales, and a demographic form. Overall, NPs have low political efficacy. Older age ( p≤.001), health policy mentoring ( p≤.001), and specific education on health policy ( p≤.001) were all positively associated with internal political efficacy and political participation. External political efficacy was not significantly associated with any of the study variables. Political activities of NPs are largely limited to voting and contacting legislators. Identifying factors that engage NPs in grassroots political activities and the broader political arena is warranted, particularly with current initiatives to make changes to state laws and regulations that limit their practice.

Creating a successful and sustainable nurse practitioner service in the remote Kimberley Region of WA

Creating a successful and sustainable nurse practitioner service in the remote Kimberley Region of WA

The effectiveness of emergency nurse practitioner service in the management of patients presenting to rural hospitals with chest pain: a multisite prospective longitudinal nested cohort study

BackgroundHealth reforms in service improvement have included the use of nurse practitioners. In rural emergency departments, nurse practitioners work to the full scope of their expanded role across all patient acuities including those presenting with undifferentiated chest pain. Currently, there is a paucity of evidence regarding the effectiveness of emergency nurse practitioner service in rural emergency departments. Inquiry into the safety and quality of the service, particularly regarding the management of complex conditions is a priority to ensure that this service improvement model meets health care needs of rural communities.MethodsThis study used a prospective, longitudinal nested cohort study of rural emergency departments in Queensland, Australia. Sixty-one consecutive adult patients with chest pain who presented between November 2014 and February 2016 were recruited into the study cohort. A nested cohort of 41 participants with suspected or confirmed acute coronary syndrome were identified. The primary outcome was adherence to guidelines and diagnostic accuracy of electrocardiograph interpretation for the nested cohort. Secondary outcomes included service indicators of waiting times, diagnostic accuracy as measured by unplanned representation rates, satisfaction with care, quality-of-life, and functional status. Data were examined and compared for differences for participants managed by emergency nurse practitioners and those managed in the standard model of care.ResultsThe median waiting time was 8.0 min (IQR 20) and length-of-stay was 100.0 min (IQR 64). Participants were 2.4 times more likely to have an unplanned representation if managed by the standard service model. The majority of participants (91.5%) were highly satisfied with the care that they received, which was maintained at 30-day follow-up measurement. In the evaluation of quality of life and functional status, summary scores for the SF-12 were comparable with previous studies. No differences were demonstrated between service models.ConclusionsThere was a high level of adherence to clinical guidelines for the emergency nurse practitioner service model and a concomitant high level of diagnostic accuracy. Nurse practitioner service demonstrated comparable effectiveness to that of the standard care model in the evaluation of the service indicators and patient reported outcomes. These findings provide a foundation for the beginning evaluation of rural emergency nurse practitioner service in the delivery of safe and effective beyond the setting of minor injury and illness presentations.Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN12616000823471 (Retrospectively registered).

Mapping workforce configuration and operational models in Australian emergency departments: a national survey.

Objective Hospital emergency departments (ED) in Australia and internationally have been experiencing increased demand, resulting in reduced hospital quality, impaired access and adverse health outcomes. Effective evaluation of new ED service models and their effect on outcomes is reliant on baseline measures of the staffing configuration and organisational characteristics of the EDs being studied. The aim of the present study was to comprehensively measure these variables in Australian EDs. Methods Australian hospital EDs with 24-h medical and nursing cover were identified and invited to participate in the study. Telephone interviews were conducted with nursing or medical department managers to collect data related to hospital characteristics, ED workforce and training and ED service and operational models. Results Surveys were completed in 87% of the population sample (n=135). Metropolitan EDs were significantly more likely to retain higher full-time equivalents (FTEs) in several medical (staff specialist, registrar, resident and intern) and nursing (nurse practitioner (NP), nurse educator, nurse unit manager and registered nurse) positions. NPs were employed by 52% of Australian EDs overall, but this ranged from 40% to 75% depending on jurisdiction. The most commonly used operational models were FastTrack teams (72% of EDs), short-stay/observational unit (59%) and patient liaison models for aged care (84%) and mental health (61%). EDs that employed NPs were significantly more likely to use FastTrack (P=0.002). Allied health services most frequently available within these EDs were radiology (60%), social work (69%), physiotherapy (70%) and pharmacy (65%). Conclusions The present study has established a baseline measure of the staffing configuration and organisational characteristics of Australian EDs. What is known about the topic? EDs are overcrowded due, in part, to the combined effect of increased service demand and access block. Innovative service and workforce models have been implemented by health departments aiming to improve service and performance. National uptake of these service and workforce innovations is unknown. What does this paper add? The present study is the most comprehensive to date profiling Australian EDs covering hospital characteristics, workforce configuration, operational models and NP service patterns and practice. What are the implications for practitioners? Information from the present study will assist health service planners to evaluate workforce and service reform models, and to monitor trends in emergency service development.

Investigating nurse practitioners in the private sector: a theoretically informed research protocol.

To report a study protocol and the theoretical framework normalisation process theory that informs this protocol for a case study investigation of private sector nurse practitioners. Most research evaluating nurse practitioner service is focused on public, mainly acute care environments where nurse practitioner service is well established with strong structures for governance and sustainability. Conversely, there is lack of clarity in governance for emerging models in the private sector. In a climate of healthcare reform, nurse practitioner service is extending beyond the familiar public health sector. Further research is required to inform knowledge of the practice, operational framework and governance of new nurse practitioner models. The proposed research will use a multiple exploratory case study design to examine private sector nurse practitioner service. Data collection includes interviews, surveys and audits. A sequential mixed method approach to analysis of each case will be conducted. Findings from within-case analysis will lead to a meta-synthesis across all four cases to gain a holistic understanding of the cases under study, private sector nurse practitioner service. Normalisation process theory will be used to guide the research process, specifically coding and analysis of data using theory constructs and the relevant components associated with those constructs. This article provides a blueprint for the research and describes a theoretical framework, normalisation process theory in terms of its flexibility as an analytical framework. Consistent with the goals of best research practice, this study protocol will inform the research community in the field of primary health care about emerging research in this field. Publishing a study protocol ensures researcher fidelity to the analysis plan and supports research collaboration across teams.

Abstract TP148: Characteristics and Estimated Rehabilitation Costs for Stroke Survivors Treated in a Community-Based Interdisciplinary Outpatient Rehabilitation Program Who Return to Work

Background: Return to work is a motivating goal for many stroke survivors. Little is known about the cost, length of treatment, and characteristics of patients returning to work. Methods: Prospective observational study of stroke patients treated between 12/2014-6/2016 in an interdisciplinary outpatient rehabilitation program addressing physical, psychosocial, cognitive, communicative, driving, and vocational issues. The estimated average cost of treatment was calculated from reimbursement amounts received for skilled PT, OT, ST, and Nurse Practitioner services, including services received after patients returned to work. Results: Of 96 consecutive patients, 48% were working prior to their stroke. Of these, 9% of patients were work capable and 44% returned to work (n=20) by rehabilitation discharge (mean program length was 8 months, maximum of 34 months). Returning workers were 70% men, mean age of 56 years, 75% ischemic strokes (4 Left, 4 Right, 3 Bi-lateral hemisphere, 4 posterior circulation), and on program admit had an average NIHSS score of 3.4 (range 0-9), 40% were aphasic, 65% needed ADL assistance (55% mRS=3, 10% mRS=4). All patients working prior to their stroke were also driving and 90% of those who returned to work also returned to driving. All patients demonstrated improvements in multiple standardized rehab outcome measures. Mean treatment cost for patients who returned to work was $17,730 (60% had costs less than $7,500; 25% had costs from $7,501-$21,000; 15% had costs from $50,000-$92,000). Services continued for 75% of patients after returning to work for an average of 3.7 months(included in mean program length of 8 months). Almost half of these patients (47%) were aphasic. Mean treatment cost for patients not returning to work was $22,561, with mean program length of 6.5 months. Conclusions: These findings demonstrate that interdisciplinary, outpatient rehabilitation programs can promote successful return to work at a reasonable cost, with 60% of patients who returned to work costing less than $7500. Aphasic patients needed longer treatment, but were able to successfully return to work. Additional outcomes research is needed to understand mechanisms supporting stroke patients’ return to work and other patient-centered goals.

Hospice Visit Intensity by Physicians and Nurse Practitioners on the General Inpatient Level of Care (TH371C)

•Describe the rate of physician or nurse practitioner services during GIP service.•Describe episode characteristics associated with the rate of physician or nurse practitioner services during GIP service. The Medicare Hospice Benefit’s General Inpatient (GIP) level of care is intended to provide for pain and symptom management in an inpatient facility that could not be managed in the patient’s home. Examine how beneficiaries utilize physician and nurse practitioner services while receiving GIP care. Retrospective cohort analysis of Medicare hospice beneficiaries utilizing GIP during Federal Fiscal Year 2014 (FY2014). Using 100% Medicare hospice and Part B claims from FY2014 we examined physician and nurse practitioner service visit intensity during GIP. We found that among the 1.5 million GIP days serviced in FY2014, the majority of days (52.4%) were not associated with any recorded physician or nurse practitioner services. Rates of the absence of these services were particularly high among hospice GIP days provided in (Acute) Inpatient Facilities (69.1% of days missing physician/nurse practitioner services), Long-Term Care Hospitals (84.3% missing services), and Skilled Nursing Facilities (85.3% missing services). Moreover, one in five hospice episodes that have at least three days of sequential GIP care did not have any physician or nurse practitioner services recorded from either the hospice or Part B claims; this was true for more than half of such episodes beginning in long-term care hospitals or skilled nursing facilities. We found that over two-thirds of all GIP days are serviced in hospice inpatient units and that cancer was the most common primary hospice diagnosis at admission among GIP days. GIP is an important component of the hospice benefit and these findings underscore a recent Office of Inspector General report finding variation in the utilization of GIP.

Evaluation of an aged care nurse practitioner service: quality of care within a residential aged care facility hospital avoidance service

BackgroundReducing avoidable hospitialisation of aged care facility (ACF) residents can improve the resident experience and their health outcomes. Consequently many variations of hospital avoidance (HA) programs continue to evolve. Nurse practitioners (NP) with expertise in aged care have the potential to make a unique contribution to hospital avoidance programs. However, little attention has been dedicated to service evaluation of this model and the quality of care provided. The purpose of this study was to evaluate the quality of an aged care NP model of care situated within a HA service in a regional area of Australia.MethodsDonabedian’s structure, process and outcome framework was applied to evaluate the quality of the NP model of care. The Australian Nurse Practitioner Study standardised interview schedules for evaluating NP models of care guided the semi-structured interviews of nine health professionals (including ACF nurses, medical doctors and allied health professionals), four ACF residents and their families and two NPs. Theory driven coding consistent with the Donabedian framework guided analysis of interview data and presentation of findings.ResultsStructural dimensions identified included the ‘in-reach’ nature of the HA service, distance, limitations of professional regulation and the residential care model. These dimensions influenced the process of referring the resident to the NP, the NPs timely response and interactions with other professionals. The processes where the NPs take time connecting with residents, initiating collaborative care plans, up-skilling aged care staff and function as intra and interprofessional boundary spanners all contributed to quality outcomes. Quality outcomes in this study were about timely intervention, HA, timely return home, partnering with residents and family (knowing what they want) and resident and health professional satisfaction.ConclusionsThis study provides valuable insights into the contribution of the NP model of care within an aged care, HA service and how staff manipulated the process dimensions to improve referral to the NPs. NP service in this study was dynamic, flexible and responsive to both patient and organisational demands.

Increasing Role of Nurse Practitioners in House Call Programs.

Residence-based primary care provides homebound frail patients with a care plan that is individually tailored to manage multiple chronic conditions and functional limitations using a variety of resources. We (1) examine the visit volume and Medicare payments for residence-based health care provided by nurse practitioners (NPs) in the Medicare fee-for-service environment; (2) compare NP's residential visits to those of internists and family physicians; and (3) compare the geographical service area of full-time house call NPs versus NPs who make nursing facility visits a major portion of their work. An observational study using secondary data. Medicare Provider Utilization and Payment Data. Medicare beneficiaries. Medicare payments for home and domiciliary care visits, the number of residence-based medical visits, provider volume, geographical distribution of full-time house call providers. About 3,300 NPs performed over 1.1 million home and domiciliary care visits in 2013, accounting for 22% of all residential visits to Medicare fee-for-service beneficiaries. A total of 310 NPs individually made more than 1,000 residential visits (defined as a full-time house call provider); among full-time house call providers, including physicians, NPs are now the most common provider type. There are substantial variations in the geographic distribution of full-time house call NPs, internists, and family physicians. Full time NP's service area is about 30% larger than family physicians and internists. Nursing home residents are far more likely to receive NP visits than are homebound persons receiving home visits. NPs are now the largest type of provider delivering residence-based care and NPs provide care over the largest geographical service area. However, the vast majority of frail Americans are more likely to receive NP's care in a nursing facility versus at home.