Do More with Less
T
he marching orders are clear: “Do more with less.” This communication from a community hospital chief medical officer to the geriatrics leadership team is the context1 in which new geriatrics models are considered. This editorial describes the environment in which we are implementing geriatrics models of care. We will provide some reflections on the article by Boyd and colleagues2 in this month’s Journal of the American Geriatrics Society, and we will note how this study compares with prior descriptions of the use of advanced practice nurses in longterm care settings. We will conclude with some ideas about strategies to do more with less. Traditionally, fee-for-service reimbursement has supported emergency department evaluation and hospitalization of nursing facility residents instead of on-site assessment or clinical guidelines and coaching strategies to enhance licensed nurse interventions. As the U.S. healthcare system shifts its focus from a fee-for-service system to a value-based model, the delivery of care will undoubtedly transition as well. This is no truer than in the case of older adults in long-term care facilities, where increasingly complex care needs are stretching already thin budgets and staff. Given this context and future expectations of an increasingly older U.S. demographic, it is critical that geriatric models of care consider care and cost-effectiveness outcomes equally as we address “doing more with less.” Contributing to our knowledge at this critical junction are the results presented by Boyd and colleagues2 in this month’s Journal of the American Geriatrics Society. This group specifically examined whether the use of advanced practice nurses (APNs) influenced rates of hospitalization in 29 New Zealand residential aged care (RAC) facilities. This setting is similar to chronic supportive care that skilled nursing facilities provide in the United States. Individuals in New Zealand who require subacute care or short-stay rehabilitation services receive that care in the hospital. The design was not blinded, and the randomization occurred at the level of the facilities. The intervention was primarily a nursing staff development program with a focus on supporting staff with clinical coaching, education, and care coordination, rather than direct care. The overall time spent at each facility (the dosage or intensity of exposure) was remarkably low. Accordingly, the results were modest. The intervention and control groups had an increase in hospitalization. The intervention group had an increase in hospitalization of 16%, and the hospitalization rate for the control group increased 59%. DOI: 10.1111/jgs.13025
JAGS 62:1977–1978, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
Boyd and colleagues’ findings mirror those of other studies of APNs in long-term care, such as those of the Evercare model.3 The Evercare outcomes show that increasing nursing capacity and collaborating with physicians improves resident care and decreases systemic costs. There is good evidence that this care reduces emergency department and hospital use.3–5 Likewise, this type of collaboration in an academic nursing home practice improved functional status and resident satisfaction with care and morale.6 Because reimbursement mechanisms did not provide incentives to physicians to provide sufficient on-site care to nursing home residents, it makes sense that the addition of APNs in a primary care role with regular contact with residents would improve outcomes. Although professional organizations such as the American Medical Directors Association have supported the growth of physicians specializing in nursing home practice, the numbers remain low. Thus, other primary care providers such as APNs as part of a group practice (within a Medicare managed care model or as nursing home employees or consultants) is another growing trend. In addition to direct clinical work, some APNs work as staff educators, managers, or clinical coaches to facilitate nursing practice. There are no educational or certification requirements for licensed nurses to work in nursing homes, which means that APNs may be the only master’s-prepared nurses with advanced clinical skills and geriatric care knowledge in this setting. Boyd and colleagues capitalized on APNs in this role to heighten nursing staff proficiency in assessment and communication with primary care providers. Quality improvement interventions that enhance nursing staff skills (e.g., Interventions to Reduce Acute Care Transfers (INTERACT II)) have shown benefit for large cohorts of skilled nursing facility residents in the United States.7 Each of these strategies has used a systems-based methodology of improving a care process: identification and assessment of a vulnerable older adult (Stop and Watch), communication with other professionals about a change in resident status (Situation Background Assessment Recommendation), or assessment tools for residents with common conditions (Care Paths). Doing more with less will require us to review how we use the limited resource of our APNs. On the one hand, they provide follow up and urgent care visits and order tests and medications and thus enhance the physician workforce. In this case the APNs provide direct care in collaboration with the physician, thus extending the reach of the physician. On the other hand, Boyd and colleagues demonstrate that APNs can also implement and support health programs of indirect care at the facil-
0002-8614/14/$15.00
1978
EDITORIALS
ity level to improve the care of large populations. We would argue that such population-based approaches can enhance the clinical competencies of the direct care staff, resulting in better care for large groups of older adults while efficiently using scarce provider resources. These strategies and models should continue to support the relationship between patients and their providers. In addition, these new models need to address the context of a health system that demands that we spend less. Michael Malone, MD Aurora Health Care, and Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Milwaukee, Wisconsin Aaron Malsch, RN, MSN Aurora Health Care, Milwaukee, Wisconsin Elizabeth Capezuti, PhD, RN Department of Gerontology, Hunter College School of Nursing, City University of New York, New York City, New York
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and
OCTOBER 2014–VOL. 62, NO. 10
JAGS
has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to the invited editorial equally. Sponsor’s Role: There are no sponsors for this paper.
REFERENCES 1. Davidoff F, Batalden P, Stevens D et al. Publication guidelines for quality improvement in health care: Evolution of the SQUIRE project. Qual Saf Health Care 2008;17(Suppl 1):3–9. 2. Boyd M, Armstrong D, Parker J et al. Do gerontology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial. J Am Geriatr Soc 2014;62:1962–1967. 3. Kane RL, Keckhafer G, Flood S et al. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51:1427–1434. 4. Konetzka TR, Spector W, Limcangco MR. Reducing hospitalizations from long-term care settings. Med Care Res Rev 2008;65:40–66. 5. Reuben DB, Schnelle JF, Buchanan JL et al. Primary care of long-stay nursing home residents: Approaches of three health maintenance organizations. J Am Geriatr Soc 1999;47:131–138. 6. Weiland D, Rubenstein LZ, Ouslander JG et al. Development and impacts of an academic nursing home. JAMA 1986;255:2622–2627. 7. Ouslander JS, Lamb G, Tappen R et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. J Am Geriatr Soc 2011;59:745– 753.
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
T
he marching orders are clear: “Do more with less.” This communication from a community hospital chief medical officer to the geriatrics leadership team is the context1 in which new geriatrics models are considered. This editorial describes the environment in which we are implementing geriatrics models of care. We will provide some reflections on the article by Boyd and colleagues2 in this month’s Journal of the American Geriatrics Society, and we will note how this study compares with prior descriptions of the use of advanced practice nurses in longterm care settings. We will conclude with some ideas about strategies to do more with less. Traditionally, fee-for-service reimbursement has supported emergency department evaluation and hospitalization of nursing facility residents instead of on-site assessment or clinical guidelines and coaching strategies to enhance licensed nurse interventions. As the U.S. healthcare system shifts its focus from a fee-for-service system to a value-based model, the delivery of care will undoubtedly transition as well. This is no truer than in the case of older adults in long-term care facilities, where increasingly complex care needs are stretching already thin budgets and staff. Given this context and future expectations of an increasingly older U.S. demographic, it is critical that geriatric models of care consider care and cost-effectiveness outcomes equally as we address “doing more with less.” Contributing to our knowledge at this critical junction are the results presented by Boyd and colleagues2 in this month’s Journal of the American Geriatrics Society. This group specifically examined whether the use of advanced practice nurses (APNs) influenced rates of hospitalization in 29 New Zealand residential aged care (RAC) facilities. This setting is similar to chronic supportive care that skilled nursing facilities provide in the United States. Individuals in New Zealand who require subacute care or short-stay rehabilitation services receive that care in the hospital. The design was not blinded, and the randomization occurred at the level of the facilities. The intervention was primarily a nursing staff development program with a focus on supporting staff with clinical coaching, education, and care coordination, rather than direct care. The overall time spent at each facility (the dosage or intensity of exposure) was remarkably low. Accordingly, the results were modest. The intervention and control groups had an increase in hospitalization. The intervention group had an increase in hospitalization of 16%, and the hospitalization rate for the control group increased 59%. DOI: 10.1111/jgs.13025
JAGS 62:1977–1978, 2014 © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society
Boyd and colleagues’ findings mirror those of other studies of APNs in long-term care, such as those of the Evercare model.3 The Evercare outcomes show that increasing nursing capacity and collaborating with physicians improves resident care and decreases systemic costs. There is good evidence that this care reduces emergency department and hospital use.3–5 Likewise, this type of collaboration in an academic nursing home practice improved functional status and resident satisfaction with care and morale.6 Because reimbursement mechanisms did not provide incentives to physicians to provide sufficient on-site care to nursing home residents, it makes sense that the addition of APNs in a primary care role with regular contact with residents would improve outcomes. Although professional organizations such as the American Medical Directors Association have supported the growth of physicians specializing in nursing home practice, the numbers remain low. Thus, other primary care providers such as APNs as part of a group practice (within a Medicare managed care model or as nursing home employees or consultants) is another growing trend. In addition to direct clinical work, some APNs work as staff educators, managers, or clinical coaches to facilitate nursing practice. There are no educational or certification requirements for licensed nurses to work in nursing homes, which means that APNs may be the only master’s-prepared nurses with advanced clinical skills and geriatric care knowledge in this setting. Boyd and colleagues capitalized on APNs in this role to heighten nursing staff proficiency in assessment and communication with primary care providers. Quality improvement interventions that enhance nursing staff skills (e.g., Interventions to Reduce Acute Care Transfers (INTERACT II)) have shown benefit for large cohorts of skilled nursing facility residents in the United States.7 Each of these strategies has used a systems-based methodology of improving a care process: identification and assessment of a vulnerable older adult (Stop and Watch), communication with other professionals about a change in resident status (Situation Background Assessment Recommendation), or assessment tools for residents with common conditions (Care Paths). Doing more with less will require us to review how we use the limited resource of our APNs. On the one hand, they provide follow up and urgent care visits and order tests and medications and thus enhance the physician workforce. In this case the APNs provide direct care in collaboration with the physician, thus extending the reach of the physician. On the other hand, Boyd and colleagues demonstrate that APNs can also implement and support health programs of indirect care at the facil-
0002-8614/14/$15.00
1978
EDITORIALS
ity level to improve the care of large populations. We would argue that such population-based approaches can enhance the clinical competencies of the direct care staff, resulting in better care for large groups of older adults while efficiently using scarce provider resources. These strategies and models should continue to support the relationship between patients and their providers. In addition, these new models need to address the context of a health system that demands that we spend less. Michael Malone, MD Aurora Health Care, and Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Milwaukee, Wisconsin Aaron Malsch, RN, MSN Aurora Health Care, Milwaukee, Wisconsin Elizabeth Capezuti, PhD, RN Department of Gerontology, Hunter College School of Nursing, City University of New York, New York City, New York
ACKNOWLEDGMENTS Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and
OCTOBER 2014–VOL. 62, NO. 10
JAGS
has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: All authors contributed to the invited editorial equally. Sponsor’s Role: There are no sponsors for this paper.
REFERENCES 1. Davidoff F, Batalden P, Stevens D et al. Publication guidelines for quality improvement in health care: Evolution of the SQUIRE project. Qual Saf Health Care 2008;17(Suppl 1):3–9. 2. Boyd M, Armstrong D, Parker J et al. Do gerontology nurse specialists make a difference in hospitalization of long-term care residents? Results of a randomized comparison trial. J Am Geriatr Soc 2014;62:1962–1967. 3. Kane RL, Keckhafer G, Flood S et al. The effect of Evercare on hospital use. J Am Geriatr Soc 2003;51:1427–1434. 4. Konetzka TR, Spector W, Limcangco MR. Reducing hospitalizations from long-term care settings. Med Care Res Rev 2008;65:40–66. 5. Reuben DB, Schnelle JF, Buchanan JL et al. Primary care of long-stay nursing home residents: Approaches of three health maintenance organizations. J Am Geriatr Soc 1999;47:131–138. 6. Weiland D, Rubenstein LZ, Ouslander JG et al. Development and impacts of an academic nursing home. JAMA 1986;255:2622–2627. 7. Ouslander JS, Lamb G, Tappen R et al. Interventions to reduce hospitalizations from nursing homes: Evaluation of the INTERACT II Collaborative Quality Improvement Project. J Am Geriatr Soc 2011;59:745– 753.
Copyright of Journal of the American Geriatrics Society is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
