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How the Nurse Practitioner Has Become ‘Front and Center’ as I-SNPs Demand More Complex Care


How the Nurse Practitioner Has Become ‘Front and Center’ as I-SNPs Demand More Complex Care

The nurse practitioner (NP) role has evolved to be much more involved in the day-to-day operations of a nursing home, especially given the higher acuity that the care setting has adopted.

Institutional special needs plans (I-SNPs), which are designed to care for residents that need a higher level of clinical care, has led to more NP involvement on the ground level as well, according to senior clinicians at nursing home operator Avalon Healthcare Management Group.

Kathy Owens, senior vice president of clinical services for Avalon, has seen the NP role “really come into its own,” with the additional clinical skill set being recognized and utilized more effectively.

“We rely on them a lot heavier just because our goal has been to reduce rehospitalizations, reduce potential exposure just from sending them to the ER,” said Tonya Madaus, director of nursing at Umpqua Valley Nursing and Rehabilitation Center in Oregon, an Avalon facility. “Our nurse practitioners have had to develop and hone in on a lot of their skills, really just buckle down and become more observant with the patients, become more proactive.”

Dr. Cheryl Phillips, president and CEO of the SNP Alliance, said the evolution of the role in general has been “particularly impressive and powerful” compared to its initial introduction as a “physician extender” in the nursing home.

“Nurse practitioners are very much front and center in the clinical leadership roles within nursing homes now, particularly with new payer models,” said Phillips, referring to the I-SNP. “There still is a primary care physician, but the nurse practitioner is often there multiple times a week and has built a relationship with the nursing staff.”

The nursing practitioner has evolved to be “immensely valuable” for on-call services outside of regular business hours, Owens added, promoting stronger continuity of care and a more in-depth, in-house ability to make clinical decisions.

Owens expects NPs to have an even greater presence in the nursing home than they do now, as education duties evolve and skilled nursing facilities continue to see high patient satisfaction tied to having an NP on-site.

In turn, overall medical outcomes will get better as facilities continue to have that on-site support.

“I remember a time in our facilities where we would rarely ever see a physician in the facility and never had nurse practitioner support. It has evolved … now have a nurse practitioner in our building three days a week,” added Madaus.

Avalon partners with medical directorship group GAPS Health and Optum I-SNP Care Model for SNFs for its supply of nurse practitioners — not hiring any such roles directly, Owens said.

GAPS and Optum NPs work together to deliver routine and episodic medical care, a collaboration that has evolved over time.

In-house NPs in the time of Covid
Maggie Mullican, a nurse practitioner for Avalon, said the role became the “glue” holding clinical teams together amid pandemic turnover.

Mullican became an NP in 2020 but didn’t start practicing until 2021, serving previously as a hospital registered nurse (RN) at the start of the pandemic.

“We’re the steady person that’s in these buildings, we’re a good source of communication,” Mullican said.

The NP became the thread between families and residents when visitation was limited, she added.

More “hats” added to the NP role too, Mullican said, including mental health checks and overseeing wound care, as it became harder to get specialists into the building — a problem further exacerbated with turnover as the pandemic raged on.

“Another hat is hospice and palliative care. A lot of these hospice companies, they’re backed up, and so a lot of times I’ll manage a hospice resident instead of referring them to a hospice company,” said Mullican. “I’ll start the medicines, communicate with the family. It can be a while before a hospice company can come in.”

Timely responses from an in-house NP has been a major help throughout the pandemic, Madaus added, compared to out-of-house, less responsive NPs that can be more reactionary when they are brought in.

“Since we’re in the buildings, [physicians] feel comfortable discharging the higher acuity patients to make more room at the hospitals. A lot of times we’re managing IV antibiotics and wound care … the hospitals are also overrun, especially when COVID was at its height,” added Mullican.

NPs became more involved and proved to be a critical voice in assessing who required treatment, or who would be a good candidate for treatment, during the many phases of the pandemic.

“Providers that were in-house really played a major role in helping decide, if it was really imperative, how quickly we got people out to the hospital, before we had the vaccine and before we had monoclonal antibodies,” said Owens. “[NPs were] able to help manage the condition on site as much as possible, but also make that very critical decision of when to transport out.”

As the vaccine was rolled out and more treatment options became available, the NP helped residents, families and staff better understand the value of vaccination.

Education, and actual administration of the vaccine and monoclonal antibodies, monitoring any sort of adverse response became an added duty of the NP at a certain point in the pandemic, explained Owens.

“This adaptation is good, this has really helped my communication within the buildings, and I know that buildings appreciate that,” said Mullican.

NPs and greater risk in the nursing home
Especially for facilities that utilize an I-SNP plan, NPs have become a “driving force” behind preventing hospitalization – an NP is involved as soon as there’s a change in a resident’s condition.

Having NPs on site allows for rapid intervention with residents that are at high risk, teaching staff along the way to do the same.

“’I’m seeing that form follows finance,” added Phillips. “With the emergence of these managed models, particularly I-SNPs that were truly benefiting from increasing accountability, authority and leadership of nurse practitioners, they’re not simply seen as physician extenders, but are really part of a clinical leadership team.”

While Phillips maintains the I-SNP model has helped NPs find more autonomy in the workplace, others have seen a slight regression away from autonomy as facilities seek to make sure infection control protocols are followed.

“Facilities have been trying to supervise us more than before because they have to monitor what we’re doing more closely,” said Melinda Johnson, clinical coordinator for the Southern Illinois region at operator AbleHearts.

Johnson refers to more paperwork, more documentation needed from the NP to follow pandemic-era guidelines as surveys ramp back up – a barrier to more autonomy in the role. That’s despite the industry being in a better position at this stage in the pandemic, with vaccines available and more general knowledge concerning the virus.

Essentially, NPs as part of an I-SNP plan allow residents to “skill in place,” or get more acute care without going to the hospital, according to Owens and Madaus.

“Over time our teams really have grown to rely on that skill set and that availability – and the teaching component as well,” added Owens. “We’ve been able now to get a greater presence of an advanced clinical skill set in our facilities from several vantage points, and several different organizations.”

Another “increasingly visible role” of the NP, as Owens puts it, is as an educator for other staff, families and the residents themselves.

They’re on-site, so they’re more familiar with the residents and their families; as a familiar face, they do a lot of teaching with families, added Owens.

The NP has helped the patient, family and facility staff navigate end of life decisions.

“Our nurse practitioners have spent a lot in that situation, to come alongside the nurses to educate on the course of the patient’s illness and [give a] clear picture of what choices they have and what’s a realistic goal for them,” added Madaus.


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