Nurse practitioners (NPs) are a growing presence in nursing homes and are expected to play an even more pivotal role in the years to come, with the role tied to survey outcomes, quality improvement initiatives and value-based care.
The changing survey process, the Quality Assurance and Performance Improvement (QAPI) programs and value-based care models like the Transforming Episode Accountability Model (TEAM) are all demanding greater clinical expertise, according to nursing home leaders.
To meet policy and clinical needs, some nursing home operators, including Vierra Communities, have been hiring NPs to serve a single facility, with support from other NPs and specialists that belong to physiatry groups.
Historically, the NP played a more supportive role to the primary physician, John Njonjo, VP of clinical services for the Virginia-based provider, told Skilled Nursing News, but that has changed in recent years.
The positions have flipped, he said, so that the NP has a more primary care role when it comes to nursing home care.
“Some of this is not optional,” said Njonjo. “CMS is moving forward with value-based systems like the TEAM model, where they expect you to address rehospitalization — this is where the nurse practitioner is going to become key because the focus is going to be not necessarily on the physician, but who is able to mitigate.”
Hospitals are choosing which nursing operators to work with for the mandated TEAM model; they pay attention to operators who have NPs that are good at managing joint pain, sepsis and demonstrate strong diagnostic results, Njonjo said.
Texas-based Cantex Continuing Care Network employs 24 nurse practitioners and registered nurses (RNs), said Cantex CEO Robin Underhill. The team recognizes the value of the NP, and that they’re being utilized in so many ways.
“We are finding more that the position is stretched thin. Yes, they’re our medical director. They’re at the helm of the table talking about QAPI, and they’re representing the company in the facility,” said Underhill. “But when you go to bedside and you’re engaging with that patient, more times than not it’s the nurse practitioner — they’re driving the medical model for that patient.”
Cantex runs 37 skilled nursing facilities (SNFs), alongside multiple home health agencies, hospice agencies and pharmacies.
Generally, there will continue to be a lot of pressure on clinical outcomes, and the NP is the one who’s able to drive those clinical outcomes, Njonjo and Underhill said.
For Vierra, NPs are indeed first line of defense, since they are embedded in the day to day of each facility, and they see residents on a daily basis. The only other role that may surpass them as first line of defense are CNAs, Njonjo said.
“That’s the one main pillar that we’ve seen make a huge difference,” said Njonjo of the NP role. “These are the people who are at the front lines, preventing anything from escalating.”
The rising use of NPs mirrors the general trend in healthcare: NPs serve as primary care providers, making up nearly half of the U.S. primary care workforce, according to recent studies. They are often hired to work in community clinics, rural areas and family medicine offices.
Center-based NPs
Each of Vierra’s five facilities has, at minimum, one center-based NP, but placement is also based on census, he said. For larger buildings, Vierra has two center-based NPs.
Vierra finds value in having facility-based nurse practitioners in their buildings five days a week, working closely with their medical provider group. Having NPs embedded in the facility helps meet the needs of higher acuity patients. These clinicians also help patients and their families get their answers faster, considering how hard it is to get ahold of a physician.
Underhill added that NPs are driving the medical model for the patient.
“You’ll have your physician who works in tandem with your center-based NP, and they alternate, and they also do some rounding together,” Njonojo said. “Families can get their communication in real time. The NP who’s in facility also means that assessments are also at bedside, mitigating rehospitalization.”
In addition to the center-based NPs, Vierra works with a physiatry group for specialists like cardiologists, who also bring their own NPs into the building. Having this group come in has helped with unnecessary consult trips for residents, Njonjo said.
The mix of physiatry and center-based NPs has helped with peer-to-peer communication, with the Vierra NP doing peer-to-peer meetings with the physiatrist NP.
And, Cantex leaders have found that implementing a care plan is much easier when an NP is involved.
“Nurse practitioners can, through listening to their physician, be able to execute on the plan of care and be able to engage and be front facing,” said Underhill.
NP’s role in QAPI
Having NPs on the floor has helped with QAPI progress as well.
In one case, CMS changed criteria for determining which buildings become special focus facilities, going back and forth between survey outcomes and the number of falls with injury. Vierra’s NP was able to influence both of these measures.
Having the NP sit in on risk meetings helps drive root cause analysis for the QAPI program because NPs are seeing the resident five days a week. Their deeper knowledge of each resident’s medical conditions enable them to make informed clinical decisions that ultimately have an impact on surveys, Njonjo said.
Vierra’s NPs know each resident’s medication profile as well, offering another boon considering CMS’ heavy focus on polypharmacy, or the concurrent use of multiple meds by a single patient in the nursing home.
“More than likely, [the NP] is the one who ordered the labs. She’s the one who’s going to manage the medication profile. And last but not least, she will literally be there when the surveyors show up,” said Njonjo.
Surveyors mine their citations from provider notes, and oftentimes there’s a lot that gets lost in translation. Having NPs in the building can help surveyors get their information “straight from the horse’s mouth,” Njonjo added.
“The nurse practitioner can articulate the thought process,” Njonjo said. “That’s just one example of how they can truly impact our survey. In addition, the teaching that they’re able to do with the nurses on a day-to-day basis, that does impact clinical outcomes.”
Cantex’s NPs have been front and center when a patient has a change in condition, Underhill said. UTIs, for example, are the number one reason a patient goes to the hospital. NPs test for UTIs at the bedside and can be proactive with an IV, hydration and an antibiotic while waiting for lab results to come back.
NPs are there “just in time” to help manage the journey of care, Underhill noted.
As for Vierra’s Njonjo, using the NP role for QAPI programs and communicators on the floor is a more structured and precise way of going about business. He calls it “the prescribed clinical workflow.” With other workflows, the NP shows up and decides what information to gather, attending risk meetings, fall prevention meetings, morning meetings, to stay informed.
When the role is prescribed by the facility, however, the NP knows this information already since they are so deeply woven into the fabric of daily operations.