key: cord-0074393-q2x4w838 authors: McGilton, Katherine S.; Bowers, Barbara J.; Resnick, Barbara title: The Future Includes Nurse Practitioner Models of Care in the Long-Term Care Sector date: 2022-02-02 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.12.003 sha: a27302203e4aa76f7d5e3b4ed424f4bd04c55799 doc_id: 74393 cord_uid: q2x4w838 nan The COVID-19 pandemic hit the long-term care (LTC) sector hard, illuminating long-standing deficiencies. The pandemic revealed the consequences of years of inattention to the many challenges facing nursing homes, including lack of access to primary care providers (PCPs)dphysicians or nurse practitioners (NPs)dboth of whom bring a complementary skill set to the LTC sector. Although multiple studies have focused on the practices of NPs, 1 there is limited evidence examining physicians' practice patterns in nursing homes; however, a recent study suggests that nursing home physicians were more likely to be aged 70 years than nonenursing home physicians and fulltime nursing home physicians were less likely to take part in innovative delivery models, than occasional nursing home physicians. 2 In one of the few surveys examining physician in LTC homes, a 1991 survey demonstrated that physicians with a nursing home practice spent 2 hours per week with residents, 3 and a more recent examination of same-day physician availability in Ontario, Canada, revealed that only around 30% of 161 surveyed homes had same day physician access. 4 The lack of on-site availability of PCPs may contribute to adverse health outcomes among residents 5 and dissatisfaction from residents and their families related to the frequency of interactions with their physician. 6, 7 Finding physicians focused on care of LTC residents will no doubt become increasingly more challenging, with data from the United States demonstrating that these providers have decreased from 83% in 2008 to 59% in 2018. 8 In contrast, there has been a growth in full-time NPs from 14% in 2008 to 36% in 2018, representing 60% of full-time PCPs in the LTC sector. 8 This editorial focuses specifically on the different models of NP practice that have been developed, barriers that influence NPs' ability to provide care, the influence of COVID-19 on NPs' practice in the United States and in Canada, 9 and recommendations for the future that include NP models of care as a way in which to optimize team managed care to a vulnerable complex population. NPs, otherwise known as advance practice registered nurses, are graduate prepared registered nurses, typically with a Master of Nursing or Doctor of Nursing Practice degree, whose education and practice specializes in one of several specific areas, including adultgerontological care. The role was established in the 1960s in the United States and Canada to meet the primary health care needs of the population in light of physician shortages, particularly in rural areas. 10 NPs can perform a wide range of care services including diagnosing, prescribing medications, and performing some medical procedures as appropriate through training and scope of practice guidelines. Because of their nursing background and baccalaureate degree education, NPs have a strong focus on advanced nursing skills and medicine, psychosocial care, resident and family education and problem solving, and engaging family as care partners. In addition, NPs allocate a large part of their time coaching and educating direct care staff, 11 during which NPs act as catalysts to develop and strengthen the staff's clinical skills and increase confidence. There are multiple currently operating models of care employing NPs in the LTC sector each involving collaboration with physicians. Generally, in the United States, these include situations in which the facility hires the NP (either directly or contracted as a faculty position/ provider through an academic setting), the physician group hires the NP, the NP is employed by a primary care practice (usually with several physicians), via an independent NP practice group, through an acute care system with a focus on decreasing hospital readmissions, or through managed care programs such as the OptumCare CarePlus model (formerly EverCare) who employ NPs to oversee the care of residents in several facilities. In Ontario, models of care include attending NPs who work full-time on site and are hired by the LTC home; and NPs employed by acute care facilities [NP-Led Outreach Teams (NLOTs)] who oversee multiple homes (upwards of 15) with the aim to provide episodic support and reduce avoidable emergency transfers. In each of these models, NPs are on site in the LTC homes on an ongoing basis, some full-time, while others for episodic care, and their role complements that of physicians. 12 However, the level of compensation may influence NPs' willingness to work in the LTC sector, as salaries are lower than other health care settings. 13 Although there is a paucity of evidence reporting the impact of physicians on outcomes in LTC homes, 14 there is convincing research that shows NP models of care contribute to quality resident outcomes. 15 Systematic reviews have consistently demonstrated that regardless of the model they work within, NPs have a proven record of providing high-quality resident care across settings (Table 1) . 1,16e18 Employing NPs to provide primary and acute care in LTC facilities benefits resident outcomes, 15 and reduces the overall cost of care. 19 Managed care models have resulted in lower rates of emergency department transfers than those in traditional fee-for-service models. 20 LTC homes with NPs had lower rates of depression, urinary incontinence, pressure ulcers, and residents with aggressive behaviors; more residents experienced improvements in meeting personal goals; and family members who expressed more satisfaction with medical services. 16 By being on-site, NPs can identify changes in residents' status, treat acute medical problems prior to progression to more complex, life-threatening situations, prevent adverse outcomes, and reduce resident suffering. 15 Restrictive state practice acts and prescriptive privileges continue to be systemic barriers impeding NPs from providing optimal care. 21 In the United States, NPs have full independent practice authority in only 44% of the states, 22 and in states with restrictions on their practice, NPs cite difficulty with finding physicians to supervise them and the costs to beginning and maintaining the collaborative agreements as prohibitive to establishing practices. 23 Depending on the state, NPs' scope of practice may limit them from prescribing some medications, ordering laboratory tests or therapies, assessing newly admitted residents or obtaining reimbursement for their services. 24 Variations in NPs' scope of practice exist across Canada's provinces and territories as well, with the fewest restrictions in place in the Northwest Territories and Nunavut. One instance of this can be seen in Ontario, Saskatchewan, and Newfoundland, as NPs are restricted from ordering and interpreting diagnostic tests (ie, computed tomography scans, magnetic resonance imaging), but are allowed to do so in 8 other regions. 25 In the United States, opposition from some organized medical groups to removing legislative barriers poses an additional barrier. This opposition had been described as "outdated and from a bygone era," 9 lagging in translating research into practice, and acknowledging complementary and interdependent roles of physicians and NPs. 21 The Institute of Medicine advocates for NPs to practice at the full extent of their education and scope and to address regulatory and cultural barriers to provide the best care possible to residents. 24 Moreover, researchers have found that when NPs can work under less restrictive regulations there is an associated decrease in hospitalization rates and subsequent positive impact on quality of care and costs of health care. 26 COVID-19 provided an opportunity to understand contributions of NPs when barriers to practice restrictions were lifted. COVID-19 resulted in some immediate changes in scope of practice to increase access to care for residents in LTC settings and provided us with a natural experiment to discover if there were any negative or positive impacts to these changes in Canada and the United States. One of the changes that was made included an increased use of telehealth and having more providers, particularly Medical Directors, working offsite. 27, 28 For example, in Canada, Medical Directors in LTC homes were advised by their Medical Association to work virtually, 29 and changes were enacted granting NPs authority to assume the role of the Medical Director. 30 In the United States, federal and state legislation changes provided temporary waivers of all or select practice restrictions, for instance, permitting NPs to independently order tests and medication that previously required a physician's order. 9 Although some NPs also worked virtually, many NPs, particularly those hired by the facility, provided direct face-to-face care throughout the pandemic. 28 The removal of restrictions to NP practice did not result in any known negative outcomes. Conversely, during COVID-19, NPs contributed to positive outcomes such as successfully diagnosing and treating residents in place 28 ; minimizing adverse outcomes of residents and ensuring dignified deaths 31 ; establishing links between fragmented systems of care; coordinating and implementing care pathways with acute care facilities; developing resources, such as flow sheets outlining the process of consulting with specialists; and developing programs for virtual visits with these specialists. 27 NPs working in the LTC sector as PCPs throughout the pandemic consulted and collaborated with physicians, specialists, and other external stakeholders to ensure optimal resident care was received. 27 In addition, NPs supported the frontline staff, residents' families, and LTC homes' management teams, similar to what researchers found before COVID-19. 11 They continued to develop and strengthen the skills of staff, whose competencies required upgrading in order to provide care to the very complex COVID-19 residents. 27 Through listening, role-modeling, and working with staff at the bedside, NPs acted as a resource by providing emotional support to frontline staff who were often overworked and anxious about contracting the virus. 27 This may have helped to optimally ensure retention of staff within the home. Moreover, NPs' ability to build relationships with residents, families, and staff and provide a comprehensive, integrative approach with a more consistent presence provides further evidence that NPs are essential in LTC homes. These types of facility-based services are not consistently provided by physicians. Based on the lessons learned during the COVID-19 pandemic and the demonstrated value NPs have provided in LTC, it is important to continue to leverage NP models of care in these settings. Recommendations include (1) maintaining legislative reforms that were Continual reform of legislation and maintenance of the changes in legislation that occurred in response to COVID-19 is necessary to ensure that NPs across all states and countries can perform care activities for which they are educated, such as completion of advance directives, determination of capacity, diagnosis, management of medical conditions, prescription of medication, and ordering appropriate tests and appropriate medical supplies for residents. The successful implementation of the full scope of the NP practice may also require a collective effort to revise organizational and payer policies accordingly. 32 2. Clearly articulating the roles and responsibilities of NPs and physicians within the different models of care Clear articulation of the roles and the respective responsibilities of the NP and Physician is required for the different models of care along with acknowledgment of these roles by administrators, staff, and external partners. Future collaborative models in LTC homes will require significant formal and informal consultation between NPs, physicians, and acute care specialists to ensure a truly collaborative model. Planning and provision to address the NPs' role in LTC homes must respond to the increased complexity of LTC residents and the needs of their families and the multiple roles NPs have, including supporting staff, management, and building and maintaining links between health systems. 3. Conducting additional research to determine the optimal care models with which to achieve the best outcomes for residents, staff, and the health care system Research aimed at examining and determining optimal NP-physician collaborative models of care is needed. Appropriate models are needed to ensure all residents receive timely high-quality care, positive practice outcomes, and retention of other staff in these settings. Most recently, the Long-Term Care COVID-19 Commission, which was the independent commission launched by the Government of Ontario, Canada, recommended 1 NP for every 120 residents. 33 34 the Weitzman Institution, 35 or the Academic-Practice Partnership for APNs. 36 Such programs allow NPs to participate in residency in the LTC setting post graduation and were proposed to support NPs in training in the care of complex older adults in these settings. 37 initiated during COVID-19 and continuing to remove barriers to NP practices; (2) clearly articulating the roles and responsibilities of NPs and physicians within the different models of care; (3) conducting additional research to determine the optimal care models with which to achieve the best outcomes for residents, staff, and the health care system (eg, costs, rehospitalizations); (4); incentivizing work in the LTC sector by providing competitive salaries for NPs, and (5) developing innovative programs to engage and educate new NPs to work in LTC settings. Specifics of each recommendation are provided in Table 2 . The role of the NP in working collaboratively with physicians has been demonstrated as essential in LTC even prior to the pandemic and, as such, NPs represent an efficient solution in addressing the health care needs of residents in LTC. NPs' holistic approach to care is grounded in their nursing training, and they bring to LTC a unique role that not only supports residents but families, staff, and managers. The COVID-19 pandemic provided a useful natural experiment allowing for some expansion of practice for NPs that resulted in no negative outcomes. Skills of both the physician and NP are required in these collaborative models of care going forward. Optimistically, in response to what we have learned during COVID-19, we will continue to see a removal of barriers to practice and an increase in use of the many different models of care to ensure that all residents receive costeffective, high-quality care. 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We acknowledge the contributions of Alexandra Krassikova in assisting with the collation of the information provided by the coauthors.