NADD Bulletin Volume V Number 5 Article 2

Complete listing

The Nurse Practitioner as an Alternative to Quality Care and Cost Effectiveness in Treating People with a Dual Diagnosis

Michael Wisher, M.S.N., R.N., N.P.P., A.N.P.

Introduction

As with any consumer population, one must be able to balance quality service with the bottom line. Many times this is easier said than done. Dealing with people with mental retardation and other developmental disabilities adds a bigger challenge. With so much of the funding coming from governmental budgets and through fund raising, it is therefore important that medicine and administrators come together to determine how best to allocate these limited resources. It is also well chronicled that as the economy goes so does governmental funding, as well as charitable contributions.

One way to meet this challenge and address quality care with profit margins is the utilization of the Nurse Practitioner. Our community is already familiar with what the nurses are capable of doing and they are comfortable with them doing it. It has long been documented that professional nurses deliver quality care that not only reduce patient mortality and morbidity but also reduce hospital stays. It only makes sense that with such proven track record nurses are up to the challenge of providing care to the MR and DD population.

What is a Nurse Practitioner (NP)?

 Nurse Practitioners are registered nurses with specialized advanced academic and clinical training which enable them to diagnose and manage most common and many chronic illnesses/diseases. Advanced practice nurses provide a combination of nursing and medical services to individuals, families, and groups emphasizing health promotion and disease prevention. NPs work autonomously as well as in collaboration with a variety of disciplines to diagnose and manage patients’ health care problems. They serve as health care resources, interdisciplinary consultants, and consumer advocates. The Federal law defines NP as advanced nurse who performs services such as diagnosis, order laboratory and x rays, and prescribe medications. Such individual is legally authorized to perform (in the state in which the individual performs such services) in accordance with state laws and who meets such training, education and experience required as the Secretary has prescribed in regulations. According to New York State laws the practice of registered nursing by a nurse practitioner certified under section 6910 of the New York Education Law may include the diagnosis of illness and physical conditions and the performance of therapeutic and corrective measures within a specialty area of practice in collaboration with a licensed physician qualified to collaborate in the specialty involved, provided such services are performed in accordance with a written practice agreement and written practice protocols.

American Academy of Nurse Practitioners defines NP as a nurse who has advanced education and clinical training in a health care specialty area. Nurse practitioners work with people of all ages and their families providing information people need to make informed decisions about their health care and lifestyle choices.

History

The Nurse Practitioner role evolved as one strategy to increase access to primary health care in response to a shortage of physicians in rural America. Loretta Ford, R.N. and Henry Silver, M.D. developed the first successful program at the University of Colorado in 1965 to prepare pediatric NPs with a focus on health and wellness. Then, in the mid 1960’s Federal legislation provided financing to support the development of primary care providers. In 1971, the Secretary of Health, Education and Welfare issued recommendations for primary care interventions which stated that nurses and physicians could share responsibility, thus implying support for nurse practitioners as primary care providers. Federal monies were then made available; hence, nursing programs for NPs multiplied. By the 1970’s, there were more than 500 programs across the country that were preparing nurses to deliver primary care. According to the American Academy of Nurse Practitioners there are approximately 50,000 NPs in the United States today. NPs are found in all 50 states in variety of practice settings, especially Ambulatory and Out patient Care.

In the almost forty years since it began, research data has consistently demonstrated that nurse practitioners provide quality and cost-effective health care. Medical Economics Magazine stated “ nurse practitioners can boost productivity, improve patient satisfaction, and even save money.” The Canadian Burlington Randomized Trial reported that NPs safely and effectively managed 67% of their patients visits without physician consultation, with the remaining 33% of the patients appropriately referred to physicians for management.”

Primary Care

National Academy of Science Institute of Medicine defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” A large number of NPs are employed as primary care providers in underserved areas where physicians do not wish to practice. The NP role originated from a need for more primary care providers in underserved areas in our nation. While some Nurse Practitioners are employed in specialty areas, the majorities are providing primary care. The Institute of Medicine agreed that those trained, including many NPs, are most likely to practice primary care.

Scope of Practice

In 1993, the Academy of Nurse Practitioners created standards for practice that specify activities that falls within the NPs’ scope of practice. These standards cover qualifications, the process of care, collaborative responsibilities, documentation, consumer advocacy, quality assurance, supporting roles, and research. The general scope of services provided by NPs has three main focuses: assessment of health status, diagnosis, and case management.

Assessment of Health Status

1.Obtain relevant health and medical history

2.Perform physical examination, based on age and history

3.Conduct preventive screening procedures based on age and history (e.g. hearing, vision, dental, cancer)

4.Identify medical and health risks and needs

5.Order appropriate diagnostic tests

6.Developmental assessment, evaluation and referral

Diagnostic

1.Order appropriate diagnostic tests

2.Formulate appropriate differential diagnosis based on history, physical examination and clinical findings

Case Management

1.Identify needs of the consumer, families or community based on evaluation of data collected

2.Identify, implement and evaluate appropriate care plans including pharmacological and nonpharmacologic interventions

3.Provide relevant consumer and family education

4.Refer to other health professionals and agencies

5.Reevaluate and modify care plans as necessary to achieve optimal therapeutic goals.

While NP was initially created to serve rural America, NP’s have been employed in a wide variety of practice settings. Today, new roles are expanding. NPs can be found in different settings such as:

1.Community Health Centers

2.Public Health Departments

3.Hospitals\ Hospital clinics

4.School\ College Student Health Clinics

5.Business\ Industry Employee health Settings

6.Physicians Offices

7.Nurse Practitioner Office

8.Health Maintenance Organization

9.Nursing Homes\Hospice

10.Home Health Agencies

11.Armed Forces\Veteran’s Administration Facilities

12.Schools of Nursing

Benefits and Cost Effectiveness of NPs

More and more members of the medical community are choosing Nurse Practitioners to compliment their medical staffs, because many administrators have observed that NPs:

1.Provide individualized patient care emphasizing not only on health problems but also on the effects health problems have on people and their families.

2.Teach patients in regard to health problems, medications, and other topics to help patients understand how to take care of themselves.

3.Inquire about patients’ worries and concerns about their health and health care

4.Emphasize wellness and self-care by educating consumers to healthy lifestyle choices and health care decisions.

5.Charging competitive fees, which are covered by most insurance.

Many heath care administrators believed in the concept of health promotion services, which is to increase the effectiveness of recovery and reduce the number of repeat episodes of illness. Nurses have long been recognized for their expertise in patient education, counseling and case management skills. NPs cost 40% less than physicians and are cost-effective in preventive care. Research has demonstrated that Nurse Practitioners can manage 80-90% of what physicians do without the need for consultation or referral. The Department of Health Human Services reports that a comparable office visit between a nurse practitioner and a physician can range from 10-40% less in favor the of NP without compromising patient satisfaction and quality of care.

The State University of New York (SUNY) performed a cost analysis study comparing the cost of providing services at a Nurse Practitioner managed facility for the homeless with other community based programs. The study demonstrated earlier and less costly intervention by the NPs. TennCare, Tennessee’s state managed MCO (managed care organization) reported that their data showed that Nurse Practitioners delivered health care at a 23% below the average cost of other health care providers. This same study also demonstrated that there was a 21% reduction in hospital inpatient rates with 24% lower lab utilization rate below doctors. NPs also wrote 42% less prescriptions than other providers. In the final analysis, TennCare reported that the Nurse Practitioner providers demonstrated above-average performance in cost-efficiency while delivering top quality health care. One of the largest insurance providers in the greater New York area, Oxford Health Plans, is currently working with Columbia Presbyterian Medical Center in New York to test Nurse Practitioners in the formal role of primary health care givers for patients. It has already been demonstrated that patients who work with NP’s at Columbia are less likely to need hospitalization for asthma attacks. Oxford VP (Vice President) had said, “We already know that proactive management of patients will reduce ER and office visits.” Recent literature has found that employing Nurse Practitioner fully could save 20% of the cost of primary care. It is estimated that the United States may be spending up to $8.75 billion dollars that could be saved by utilizing NPs. Many insurance companies are moving into independent practitioner because research has demonstrated financial benefits of using Nurse Practitioners. On the federal level, the Federal 1999 Balanced Budget ACT allows for Medicare to directly reimburse NPs nation wide. CHAMPUS and the Federal Employee Health Benefit Program also allow the federal government to reimburse Nurse Practitioner. Washington also allows nurse practitioners to participate in the Medicaid program whether or not the NP is employed by or supervised by a physician.

Some states allow NPs to be independently reimbursed, prescribe medication and admit patients to a hospital while working in collaboration with or in some cases independently of physicians.

Utilization of the NP

The PSCH Habilitation Clinic currently utilizes the services of nurse practitioners. The medical department has a Family Practitioner who provides gynecological as well as medical services. Her function is one that incorporates medical management with traditional nursing services. Consumers, families, and staff appreciate her expanded knowledge base, which often is very helpful in matters of education and compliance.

The department of psychiatry at the clinic also utilizes the nurse practitioner model. This clinician is dually licensed in both medicine and psychiatry. The blending of both disciplines gives the NP a more comprehensive understanding of the pathologies that may lead to illness, as well as modalities that may alleviate them.

In August, 2001, a comparative cost analysis was conducted by the clinic’s administrative staff, and it was determined that the cost per unit was less for the nurse practitioner compared to the physician staff. The unit cost for a staff psychiatrist is $73.33 compared to $43.33 for the nurse practitioner. This is a realized savings of $30.00, which this time of fiscal belt tightening can be allocated to other areas of consumer care. One of the beneficial effects of reduced unit costs in regards to consumer care is that the Clinic can afford to allow the NP to spend more time with the consumers, families and staff to ensure that all parties fully comprehend the treatment plan. Another benefit that the PSCH clinic realized was that because of cost efficiencies they were able to have problematic consumers evaluated in more nontraditional treatment settings, such as day treatment centers, community housing and day habilitation programs. This allowed for better treatment outcomes for noncompliant consumers that might have otherwise been lost to the system.

For example in 1999 a pilot program was developed in which a nurse practitioner was placed into one of PSCH’s group homes, to deliver psychiatric services. The residence housed 10 consumers and all received care from the NP except for one. The treatment objectives were to deliver comprehensive care for the consumers, with the addition of all other treatment disciplines being present. The concept was to ensure that all other disciplines could work together in developing the best possible treatment plan. After one year, the general consensus was that the program did meet the treatment objectives, so much so that the program remains in operation to this day.

The nurse practitioner model at PSCH has been able to strike a balance between quality care and costs. At the same time it is utilizing the NP to the fullest extent within their scope of practice, without ever forgetting that the nurse practitioner is a compliment to physicians, not a replacement.

Conclusion

The role of the Nurse practitioner continues to evolve in response to changing societal and health care needs. As a profession, we are poised, ready and capable of delivering the health care patients expect and want. The research literature has consistently supported the favorable patient outcomes with NP care. Probably the most compelling argument for utilizing the nurse practitioner can be found in a major medical journal of our time, JAMA (Journal of American Medical Association). In their January 5, 2000 issue, they published a research article entitled ‘‘Primary Care Outcomes in Patients Treated By Nurse Practitioners or Physicians’’. The goal of the study was to compare outcomes for patients randomly assigned to nurse practitioner or physicians for primary care follow-up and ongoing care after an emergency department or urgent care visit. The study was conducted at Columbia Presbyterian Center of New York between August 1995 and October 1997. The authors concluded, “ The results of this study strongly support the hypothesis that, using the traditional medical model of primary care, patient outcomes for nurse practitioner and physician delivery of care do not differ.”

In the final analysis this article is not trying to minimize the physician role in providing care to the MR/ DD population. It is an attempt to demonstrate how the nurse practitioner role can compliment it, and deliver better care to our consumers.

Enough said, Mr. Jones, the Nurse practitioner would see you now.

References

American Academy of Nurse Practitioners. (1992). Scope of practice for nurse practitioners. Washington, DC: Author.

American Academy of Nurse Practitioners. (1993). Standard of practice. Washington, DC: Author.

Buppert, C. (1999). Nurse practitioner’s business practice and legal guide (pp. 1, 7, 9, 30, 127-129). Gaithersburg, MD: Aspen Publishing.

Hickey, J. V. (1996). Reformation of health care and implications for advanced nursing practice. Advanced Practice Nursing (pp. 3-21). New York: Lippincott-Raven.

Hooker, R., Potts, R., & Ray, W. (1997). Patient satisfaction: Comparing physician assistants, nurse practitioners, and physicians. The Permanente Journal (Portland, OR).

Lenci, B. (1999). The nurse practitioner in general practice: A retrospective study of clinical outcomes. NHS Executive (London, UK).

Lowes, R. (1998). Making midlevel providers click with your group (Importance of physician assistants, nurse practitioners, and nurse midwives to a group medical practice). Medical Economics.

McGonagle, S. (1992). Mid-level practitioners: Their role in providing quality health care, #64. Policy Research Project on Health Care Cost and Access (Austin, TX, Lyndon B. Johnson School of Public Affairs).

Mundinger, M., Kane, R., & Lenz, E. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: A randomized trial. Journal of the American Medical Association, 283, 59-68.

Sherwood, G., Brown, M., Vaunette, F., & Wardell, D. (1997). Defining nurse practitioner scope of practice: Expanding primary care services. (Houston, TX).

For more information:

Michael Wisher, M.S.N., R.N., A.N.P., N.P.P.
Nurse Practitioner Medicine/ Psychiatry
Associate Medical Director, PSCH Habilitation Clinic
25-34 Steinway Street
Astoria, NY 11103
Tel: (718) 777-5243; Fax: (718) 777-5250