APRNs, also known as advanced practice registered nurses, have been working in the nurse home setting for quite some time.
They can perform all components of the medical visit, including reviewing the medical records, medication reconciliation, follow-up care, testing, advance care planning, and developing a plan of care for the residents.
Nurse practitioners act as first- and second-line medical and psychiatric providers in skilled and nonskilled nursing home settings.
The APRNs provide clinical support to the patients when they get sick, need regulatory visits, or are discharged home. The advanced registered nurse practitioner follows evidence-based medicine when rendering care to the patient.
The services they provide to the residents of these homes keep them out of the hospital ad on the path to recovery.
Nurse practitioners provide leadership in many forms, such as directing a medical code, educating other staff members, and acting as an advocate for both the patient and the nursing home.
The nursing homes need medical providers that can assist them in making the correct decisions regarding the resident’s care.
Nurse practitioner tasks in the nursing home?
- Provide clinical care for the residents
- Review and sign document
- Assist with the drug prior authorizations
- Utilization reviews for assisting the facility in getting more time for the resident in the nursing home.
- Education of staff members
- Providing regulatory visits
- Discharging patients from the facility
- Seeing the resident upon arrival and reviewing/approving the orders and medications
- Family meetings
- Hospice and code status discussions
- Attend quarterly medical staff meetings
- Provide guidance during state inspections
- Assist in avoiding unnecessary rehospitalizations
- Prescribe and adjust medications and reduce Medications when possible
Do APRNs assist the Doctors assigned to patients in the nursing home?
Gerontological nurse practitioners can perform multiple tasks in the nursing home. They help lighten the load of the doctors rounding in the home.
Previously, doctors would have to sign all the documents, such as physical therapy orders and pharmacology recommendations, but now the APRNs have taken on this task.
The APRN can alternate regulatory visits with the doctor after the third month. These federally mandated visits evaluate the patient and review the resident’s medications, labs, and condition. The orders for the patient are then signed for compliance. Click here for an article on how to do a regulatory visit in the nursing home.
Most facilities utilize the APRN for covering after-hours on-call facilities. The nurses and APRN will call the doctor for things that need higher-level support or as a second opinion.
When the patient first arrives at the facility, the advanced practice nurse often sees them. They will review the paperwork from the hospital, approve the orders with the nurse, and make sure the patient doesn’t have any unstable or untreated illnesses that need to be addressed.
Patients will need medication reviews with possible medication reductions. If you would like to learn tips on reducing medications for the elderly in the nursing home, click here.
The nurse practitioner can also complete discharge examinations. The patient will need medications when they go home, and the provider can call the medications into the pharmacy.
By calling the medications into the pharmacy, they will review the medications for safety and perform medication education.
Most importantly, the patient will be evaluated to determine if they are safe to go home. By having a medical evaluation before leaving, they can see if it is a safe discharge. If more time is needed, the APRN can do a “peer to peer” with the insurance company to get their time extended.
They can answer any last-minute questions from the patient and family members. Many medications are confusing for families and patients and need some more explanation.
If you would like to learn how to discharge the patient from a nursing home as a medical provider, there is a great how-to discharge patient article here.
What is the impact of Nurse Practitioners in the post-acute care setting?
The impact of APRNs in the nursing home setting is hard to quantify. They perform so many roles in providing care for sick residents.
In an article written in nursingcenter.com, “While the total numbers working in nursing homes aren’t known, estimates show that fewer than 2% of NP’s work in long-term care facilities; we also know that much of geriatric nurse practitioner (GNP) care is given by adult nurse practitioners (ANPs) and family nurse practitioners (FNPs).”
Most days, the nurse practitioners will directly impact the care of residents and assist the staff in the home.
Culture of the nurse practitioner in the nursing home
Nurse practitioners usually arrive at the nursing home in the morning and check-in with the supervisor or go directly to the unit to look in the “binder” containing any visit requests the previous shift requested.
The APRN will start their rounding list, review the medical records, discuss patients with the nurse, and evaluate the residents.
Most APRNs do their best not to get caught up in the politics of the facility. They come and go and try not to gossip.
Many homes have the same problems and concerns that hospitals do. There may be rumor spreaders, “clicks,” and fighting among staff. However, it is usually a great place to work for an NP.
Most facilities provide lots of flexibility with scheduling and medical coverage. Need to leave to get a coffee? No issue, just take a break, come back, and finish your work.
If you need to leave for a doctor’s visit or pick up your kids off the bus, you will most likely be able to if you plan your day right.
Most companies won’t clock or track your hours as long as you meet your minimum number of patients seen per day and week.
There are also components of working with so many different personality types. You will be working with nurses, supervisors, CNA’s, other doctors, other nurse practitioners, and specialists.
You will be running into issues that are not experienced by providers in other settings, like medical offices. There are certain policies, procedures, and ways of doing things that aren’t done in the hospital setting. You will learn the “way of the nursing home,” which will become natural for you with time.
Some people will try to “test you” or will question all your orders. Others will support you and defend your orders. Learning how to provide care and being confident will prove your worth.
Once you win the staff over by being honest, hardworking, and providing excellent care, the majority will defend you and become your friend.
Remember to listen to the nurses when they make recommendations and incorporate their suggestions into the treatment plan when possible.
Virtual visits and telehealth in the nursing home
One of the major changes that has occurred since the start of the Covid 19 pandemic is the utilization of telehealth visits.
Telehealth was around prior to Covid 19 but not on the scale that is currently available. When the pandemic started, the facilities needed another way to provide medical evaluations for their patients. Telehealth was perfect for doctors, APRNs, and Physician assistants providing care in the nursing homes.
The medical providers are able to perform medical visits remotely with the assistance of someone in the nursing home. A nurse, CNA or other staff member would use a phone with an app such as Doximity dialer, Zoom, Doxy.me, and more. The pandemic even allowed providers to start using everyday apps such as FaceTime, google Duo, and WhatsApp to perform the remote exams. However, now they are returning to the days of using HIPPA compliant applications.
APRNS have played a large role in telehealth utilization in nursing homes. APRNs will often take the lead when it comes to telehealth visits. This doesn’t mean that doctors do not utilize telehealth, it just means that nurse practitioners are often the ones managing the first call to the virtual service, with escalation to the medical doctor when needed.
What can be done by a nurse practitioner via telehealth for a nursing home?
–Manage after-hours on-call with video visits
-Evaluate patients for sick calls
-Chronic care management
-Evaluation of new patients to facility with approval of medications and orders
-Emergency management with in facility provider is not available
-Pysch medication management
-Psychological testing such as AIMs testing
-Talk therapy
VirtualWalkinCenter.com is a company that provides virtual telehealth visits in the State of Connecticut. They also have blog on telehealth that may be of interest to you regarding the utilization of telehealth.
If you need more information on the role of medical providers and telehealth, check out our post “The New Definition of Online Doctor” for a more complete explanation.
The average salary of a gerontological Nurse Practitioner?
The average Geriatric Nurse Practitioner salary is $108,406 as of September 27, 2021, but the salary range typically falls between $99,750 and $123,549. (Salary.com)
These salaries don’t appear to include bonuses and benefits that may be available for the employees.
Most companies provide between two to four weeks of vacation. Extras such as mileage reimbursement are not reimbursed unless traveling further than usual.
Salary ranges vary depending on multiple factors such as certifications, additional skills, the number of years worked, and location.
How to start working as a nurse practitioner in a nursing home
There are multiple ways to become an APRN in a nursing home setting. You can be directly employed by the nursing home, work for an independent doctor, join a larger medical group, work for an insurance company, or be an independent contractor.
Of these options, working for an independent doctor or medical group is the most common path to working in a skilled nursing facility. You don’t see nurse practitioners working directly for the nursing homes much due to restrictions on what APRNs can do and billing concerns.
Working for a nursing home: Some homes like to have the nurse practitioner directly employed. Being directly employed allows them to have more control of who they have covering the home, the hours the APRN is in the building, and the provider’s consistency.
Cons: There are limitations regarding what the APRN can do for the patient and facility. There is also the cost of hiring a nurse practitioner to work for them.
Join an Insurance company: When you work for the insurance company, you will only see patients that the company provides or subcontracts.
The primary focus will be on capturing the patient’s diagnosis so that the insurance company can collect more money from Medicare.
You will still provide medical care to your residents but will need to document more than average in the EHR to collect all the required data sets.
You will need to save the insurance company money by being extra selective regarding ordering meds and services (which all providers should do anyway) and avoid hospitalization of the residents.
However, both tasks are things all nurse practitioners should be doing anyway. You will have access to training that should prepare you to be successful in this setting.
Cons: Some people feel they are working for the enemy, but this isn’t fair. You will be providing quality care to the residents. It will just be up to you that you aren’t pushed to do something that isn’t right for the patient.
Working for an independent physician: This can be a rewarding experience when you have a doctor who works as a teammate and acts as a collaborative MD.
The pay is sometimes salary vs. percentage of collections. The APRNs sometimes work in the office setting when the work in the nursing home is not busy enough. Some may even provide home visits on a case-by-case basis.
Cons: pay is usually less than other settings. Most make up for this by providing a better quality of life for the provider.
Medical Groups: The nurse practitioners are employed by medical groups owned by independent companies, hospital groups, and investment groups.
These medical groups are set up with a broader structure, policies, and procedures. There are usually training programs in place to streamline the onboarding process of the nurse practitioner.
The medical groups are competitive with salaries and benefits packages for employees and usually offer the ability to be promoted within.
Cons: Since you work for a larger company, the owners may not know who you are or what you provide for the company.
Independent Contractors: the APRNs can sometimes work for other doctors as independent contractors (1099) employees and are paid per visit.
The APRN is responsible for paying the taxes and liability insurance. They set the schedule for coverage based on their availability and the needs of the facility.
Some APRNs have collaborative MDs and try to find nursing homes that they provide services for and bill insurance companies directly. Some states have independent practice ability, but they still require oversite by an MD due to Medicare rules and regulations.
Cons: You need to make sure you put enough money aside for taxes. You also need to do more behind-the-scenes work such as bookkeeping, payroll, billing, collections, credentialing, etc.
If you are looking to go this way, make sure to get Nurse Practitioner’s Business Practice and Legal Guide by Carolyn Buppert to educate yourself on the rules and regulations of working for yourself.
State requirements and cultural norms of the nursing homes will also help determine how most APRNs are employed. The role of NPs in LTC is incredibly bright as the shift to value-based care will increase the need for greater primary care services in SNFs—a role NPs are well suited to fill.
Conclusion:
Nurse practitioners have taken on a much wider role in the care of the patients in the nursing home. They are usually the first provider the patients will see on arrival and the last one before being discharged to the community.
By having dedicated APRNs in nursing homes to provide care, the patient will receive quality care and hopefully have a positive experience.
Gone are the days of having one doctor that provides care without help. Now the medical attendings will have support in taking care of their residents, resulting in improved quality of life for the doctor.
Reducing unnecessary hospital admissions has become a priority in nursing homes. Advanced nurse practitioners providing medical and psychiatric care in the homes is a great and proven way to reduce unnecessary hospitalizations.
References
Nursing Counts: NPs in Nursing Homes: An Issue of Quality. https://www.nursingcenter.com/journalarticle?Article_ID=526368&Journal_ID=54030&Issue_ID=526285. Retrieved October 9, 2019
Nurse Practitioner’s Business Practice and Legal Guide, by Carolyn Buppert
Geriatric Nurse Practitioner Salary, https://www.salary.com/research/salary/recruiting/geriatric-nurse-practitioner-salary Retrieved October 9, 2021
M. Pakizegee, R. Stefanacci. Ever-Expanding Role of Nurse Practitioners in LTC. https://www.hmpgloballearningnetwork.com/site/altc/articles/ever-expanding-role-nurse-practitioners-ltc Retrieved October 9, 2019
