Nurse Practitioners and Home Care

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A recent article titled “Increasing Role of Nurse Practitioners in House Call Programs” published in December 2016 by the Journal of the American GeriatricsSociety caught my eye. House calls were, at one-time, standard practice in the provision of healthcare in the United States. I can remember as a child, the family physician coming to our home when one of us was ill. All he needed was his leather “doctor's bag.” This practice started to wane when sophisticated diagnostic equipment began to shift visits to offices, clinics, or emergency departments, and reimbursement from Medicare made it advantageous to limit encounters to an office setting. By the 1970s, the practice was out of vogue—with only a few older physicians making house calls. I recall many home care patients having to pay for expensive ambulance transportation to their physician's office because the physician would no longer write orders if they hadn't examined the patient in-person within a year. This trend started to reverse itself a few years ago as point-of-care testing has become more readily available, and we recognize the potential contribution of nurse practitioners in home care, particularly in the area of preventing hospital readmissions and emergency department visits.
The authors of this article used Medicare payment data to: a) analyze the role of nurse practitioners in the care of homebound frail older adults; b) determine the number of visits made by nurse practitioners in comparison to those made by physicians; and c) compare the service areas of those who care for patients in their homes versus residential facilities. The authors cited the tremendous number of older adults with three or more deficits in activities of daily living—an estimated four million—as well as approximately one million homebound patients who are confined to bed. According to Yao et al. (2016), “Frail homebound older adults account for about half of the costs generated by the top 5% of Medicare beneficiaries and for 29% of all Part A and B costs, 46% of Medicare 30-day readmissions, 24% of Medicare hospitalizations, 38% of all long-term institutional care, and have a 23% annual mortality.”
The researchers found that 3,300 nurse practitioners had become the largest group providing care to residents in their homes, with 1.1 million residential visits in 2013! Visits tend to cluster along the coasts (New England, Southern California, and Florida, as well as the Great Lakes region). This may reflect population density, but may also be due to work environment in various states. Although numerous models reflected cost savings, the model that was exclusively composed of nurse practitioners was the most successful at cost reduction. Despite these findings, only 21 states and Washington, DC, fully recognize the full scope and capabilities of nurse practitioners. Frail older adults will continue to increase in numbers as healthcare becomes more and more successful at treating chronic disease and other comorbidities. Providing care coordination from the home is a new reality. Nurse practitioners do more than just make an isolated visit—they are uniquely qualified to provide primary care, chronic disease management, health education, and referrals when indicated. Does your state recognize the potential contribution of advanced practice nurses to the care and well-being of the homebound community dwelling patients? Can advanced practice nurses work to the full extent of their education and training? Visit:
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