Rose, a frail, 90-year-old, retired school teacher diagnosed with dementia 10 years ago, lives in a memory care unit of an assisted living facility (ALF). For the past 5 years, she has been a patient of a nurse practitioner (NP) –led home-based primary care (HBPC) practice, receiving complex chronic disease management and palliative care for her many comorbidities. Her goals of care include do not attempt resuscitation (DNAR) and to receive comfort-focused treatment measures.
On a Friday of a holiday weekend, caregivers reported her health status had declined over the past few days. Rose refused medications, was not eating well, and demonstrated aggressive behaviors toward staff and other residents. The NP made a HBPC home visit that day. After examining the patient and finding no obvious acute disease process, he reviewed her current medications and advance health care directive (AHCD), spoke with her family, drew blood, and ordered laboratory tests. He instructed the ALF caregivers in strategies to manage the patient's behavioral and psychological symptoms of dementia, as well as ways to enhance her hydration and to call him if the patient experienced worsening symptoms. Because of the specialized regulations governing ALFs and the fact these settings are non-medical, the NP followed up by making a referral to a Medicare-certified home health agency to assist with co-management of Rose's change of condition, knowing the home health nurses would admit and follow the patient over the weekend to monitor her vital signs and report to the NP, as necessary. Before he left the ALF, the NP reaffirmed his findings and recommendations with the patient's family who concurred with the treatment plan and verbalized their pleasure that Rose would remain in the ALF to receive comfort-focused care from staff who knew her well, in the setting she was familiar with, rather than sending her to an emergency department (ED).
The home health agency received the referral but declined to start service until they received a physician signature authorizing care. Because of the holiday weekend, the NP's collaborating physician, although reachable by telephone, was unable to sign the referral document. Consequently, over the weekend, the ALF had Rose transported by ambulance to the ED where her agitation was treated with antipsychotic medications and she was transported back to the ALF later that evening. This care was incongruent with Rose's AHCD, and from multiple perspectives, came at quite a cost—costs to Medicare, costs to the patient and family, and most significantly, the cost of the emotional distress an individual with dementia experiences outside her familiar surroundings in an ED environment undergoing treatment that carries the risk of worsening her symptoms or causing other adverse events.
Current and Projected Statistics on Medicare Spending
Approximately 60 million individuals were enrolled in Medicare in 2017 and spending for the program was >$706 billion (Centers for Medicare & Medicaid Services [CMS], n.d.d). The Congressional Budget Office has predicted a rapid climb in Medicare spending over the next decade as a result of retiring Baby Boomers with higher care needs and expectations. This rate of spending is unsustainable, with the Medicare Trust Fund projected to be insolvent by 2026 (Davis, 2018) and total U.S. health care expenditures predicted to reach $6 trillion in 2027 (CMS, 2019).
Effects of Chronic Disease and Functional Limitations on Medicare Spending
Like Rose, who has eight comorbid conditions, a review of the CMS statistics from 2015 illustrates that the 15% of Medicare beneficiaries with six or more chronic conditions accounted for 51% of Medicare spending and 77% of hospital readmissions (CMS, n.d.a). The Lewin Group (2010) report, published in 2010 for the U.S. Department of Health and Human Services (USDHHS) entitled, Individuals Living in the Community with Chronic Conditions and Functional Limitations: A Closer Look, studied the impact of the costs of care for individuals with underlying chronic conditions associated with the additional costs of superimposed functional limitations. Statistics revealed the costs of care for individuals with chronic conditions and functional limitations were approximately double those with chronic conditions alone (Figure 1 and Figure 2). The report concluded that focusing care coordination across settings and social services on individuals with chronic conditions and functional limitations will improve lives and control health care spending (The Lewin Group, 2010).
Medicare spending by chronic condition.
Source. Centers for Medicare & Medicaid Services (n.d.a, in the public domain; permission is not required).
Hospital readmission by chronic condition.
Source. Centers for Medicare & Medicaid Services (n.d.a, in the public domain; permission is not required).
Rose's case is not unique. Her struggle is repeated throughout the country. Traditional routes of health care delivery that are often fragmented do not meet the needs of individuals with multiple chronic conditions and functional limitations, nor do they reduce the burden of unnecessary health care costs. Frequently, patients with cognitive and/or functional limitations seek health care services in more expensive settings, such as EDs or hospitals at later stages in the illness trajectory because of their difficulty traveling to an office setting, long wait times in the office setting, and lack of time for an adequate assessment of all factors contributing to their disease state. Many times, these more costly visits could have been prevented through a comprehensive model of health care delivery that accounts for their functional limitations as well as social and other factors contributing to poor health.
Health Care Delivery Model to Address a Vulnerable Homebound Population
For Rose and the 2 million home-bound older adults (Ornstein, Leff, & Covinsky, 2015) like her across the United States, there is a way to address the multiple facets of this problem and promote the Triple Aim of health care, which includes patient satisfaction, quality, and cost of care. HBPC practices have made a significant resurgence over the past 10 years. House calls of a bygone era have resurfaced to meet the needs of this vulnerable population of aging frail older adults, living with complex chronic health issues, burdensome symptoms, disability, cognitive and functional limitations, and often lack of adequate access to requisite caregivers and other social services. The provision of HBPC is where the medical and the social meet and has been proven to cut the overall cost of providing health care to the costliest subset of Medicare beneficiaries. HBPC provides the right patient the right care in the right place at the right time. Multiple studies have shown HBPC to be patient-centered, coordinated, less costly, and beneficial in improving quality of life. In all homebound and semi-homebound populations, CMS (n.d.b) reported fewer hospital readmissions and ED admissions for beneficiaries receiving primary care at home. A few research examples include:
- U.S. Veterans Affairs (VA) data on the HBPC model demonstrates 24% lower VA costs and 11% lower Medicare costs associated with its use due to lower hospital and nursing home use (Kinosian, Edes, Davis, & Hossain, 2010).
- Independence at home demonstration projects have shown cost savings averaging $111 per month per patient over 3 years (CMS, n.d.b).
- The MedStar Washington Hospital Center HBPC program demonstrated 17% lower Medicare costs, averaging $8,477 per beneficiary over 2 years, with lower hospital and skilled nursing facility costs. These savings were achieved despite providing the patient more primary, home health, and hospice care in the home (DeJonge et al., 2014).
The Opportunity: NPs are a Natural Fit as HBPC Providers
A 2018 report prepared for the Association of American Medical Colleges entitled, The Complexities of Physician Supply and Demand: Projections from 2016 to 2030, projected a primary care shortage of between 14,800 and 49,300 physicians by 2030 (Dall, West, Chakrabarti, Reynolds, & Iacobucci, 2018). Given the education, training, and expertise of NPs, and the data that support the practice and outcomes of care provided by NPs in primary care, NPs are a natural fit for the provision of HBPC services.
Multiple studies have shown NPs are uniquely trained and prepared to provide and coordinate HBPC services that assess and address whole person aspects of health, including medical, psychosocial, and spiritual realms of health and quality of life, all at overall cost savings to Medicare (Buerhaus et al., 2018; Francisco et al., 2018; Oliver, Pennington, Revelle, & Rantz, 2014). In the 2018 study by Buerhaus et al., it was found that key strengths of primary care NPs were in decreasing preventable hospital admissions, readmissions, and inappropriate ED use. It is of interest to note that multiple studies over the past 40 years have found NP health outcomes to be comparable to physician outcomes (Buerhaus et al., 2018; Francisco et al., 2018; Mudlinger et al., 2000; Newhouse et al., 2011; Oliver et al., 2014).
According to the 2017 Moran data on Medicare billing prepared for the American Academy of Home Care Medicine and Home Centered Care Institute (HCCI), NPs are currently the largest segment of health care professionals providing HBPC to older adults. Of the 5,306,500 HBPC visits made in 2016, NPs performed more than 2,023,000 by providing home and domiciliary visits (Figure 3) (The Moran Company, 2019).
National home-based primary care by providers (The Moran Company, 2019). Reprinted with permission from Home Centered Care Institute.
Note. PM&R = Physical Medicine and Rehabilitation.
What Do NPs Bring to HBPC?
HBPC is often provided by a team of multidisciplinary professionals in a collaborative approach to care. The ideal HBPC team may comprise physicians, advanced practice professionals (NPs/physician assistants), nurses (RNs, licensed practical/vocational nurses), medical assistants, social workers, and pharmacists. Different locations and practice structures may have different team profiles or may be a single-provider practice. HBPC practice is patient-focused ensuring all members, including patient and family, play a direct role in decision making and patient care (HCCI, n.d.).
HBPC visits offer many types of Medicare-covered services, including evaluation and management, chronic care management, transitional care management, the Medicare annual wellness visit, and advance care planning. Providers may average four to six home visits per day providing medical services, including physical examination, diagnosis, care plan development, patient and family education, and coordination of services. Medications can be reconciled, ordered, or refilled, and diagnostic tests or treatments ordered if necessary. HBPC practitioners partner with community service providers, such as durable medical equipment companies, phlebotomists, and mobile diagnostic companies, to perform laboratory draws, radiographs, ultrasounds, electrocardiograms, and other tests in the home. Home health and hospice services are frequently ordered for a variety of nursing or therapy needs, and agency clinicians become an integral part of the HBPC team (Brassard, 2012). NPs may also bill for Medicare home health and hospice care plan oversight.
The Challenges: Barriers to Care
Despite well-established HBPC practice, regulatory and reimbursement policy barriers often prevent efficient and effective use of NP services and may delay access to care for older adults. Two notable examples of these burdensome barriers include:
- NP inability to certify, re-certify, or sign orders for Medicare fee-for-service home health, despite being recognized by Medicare and Medicaid as primary care providers. This antiquated restriction stems from original 1965 Medicare language stipulating the “physician must sign” for home health orders and has not been changed to reflect current health care delivery or recommendations from the Institute of Medicine Future of Nursing Report, Federal Trade Commission, National Health Care Workforce Commission, and American Enterprise Institute. This restriction has nothing to do with scope of practice. Ordering of these same services as outpatient rehabilitation or in long-term care facilities or hospital settings is well within the scope of NP training, education, and certification (Brassard, 2012).
- NP inability to certify terminal illness for hospice patients despite being named as “attending physician” (CMS, n.d.c) of record by the patient on selection of the hospice benefit.
Rose was referred to the home health agency based on her medical need for services and to provide her care according to her AHCD in the setting of her choice. NPs working with older adults will inevitably refer patients to home health and hospice agencies based on medical necessity and what is appropriate for the patient's needs. Workarounds associated with obtaining a physician signature for these Medicare services often delay care for patients who chose an NP as their primary care provider and confuse agency clinicians who have the name of the physician who signed for services but may have never seen the patient. The end result is that the NP, who is the patient's primary care provider, may not receive timely communication or information on patients. This communication breakdown can be especially problematic in states with full practice authority, where NPs often develop physician agreements and pay a fee to a physician for signatures on certifications, re-certifications, certification of terminal illness, or supplemental home health orders.
Removing Barriers to NP Practice
As the population continues to age with its associated health care costs, the need for HBPC and complex chronic disease management will also increase. The role NPs play in HBPC will continue to grow in importance and the need to relieve barriers to advance practice RN (APRN) practice will grow as well. Legislative action or changes in the regulatory definition of the term “physician” are necessary to remove these barriers. Recent sentinel reports on NP practice such as Secretary Azar's 2018 Reforming America's Healthcare System Through Choice and Competition (USDHHS, U.S. Department of the Treasury, & U.S. Department of Labor, 2018), Buerhaus' 2018 research on Nurse Practitioners: A Solution to America's Primary Care Crisis, the Federal Trade Commission 2014 report Competition and the Regulation of Advanced Practice Nurses, and Institute of Medicine 2010 Future of Nursing Report (Sullivan, 2018) discuss the safety, quality, and benefit to patients, the health care system, and the nation's health resulting from relief of APRN barriers to practice.
Senate Bill 296 introduced in January 2019, entitled the Home Health Care Planning and Improvement Act, would allow APRNs to order, certify, and re-certify home health. If passed, it will improve patient access to care by allowing NPs to provide patient-centered care in the most efficient manner. Dobson DaVanzo & Associates (2014) estimated that the Medicare cost savings by relieving this barrier alone would generate an $82.5 million savings over 5 years. Most importantly, allowing APRNs to order, certify, and re-certify home health and certify terminal illness for hospice services will allow patients, like Rose, to remain in their setting of choice without the unnecessary burden of costly trips to the ED or hospital.
The time has come for nursing to work together to challenge the current health care delivery system. Nurses, other health care professionals, and the general public need to understand the issues and assume responsibility for the development of programs that meet the needs of patients while recognizing and fully utilizing the training, education, and preparation of NPs to care for older adults without restrictions that have nothing to do with outcomes or scope of practice. Organizations such as the American Academy of Home Care Medicine, HCCI, AARP, American Association of Nurse Practitioners, Gerontological Advanced Practice Nurses Association (GAPNA), and GAPNA House Calls Special Interest Group provide useful information, advocacy, and resources for health care professionals to learn more and engage in supporting the move to improve patient access to high-quality, cost-effective, patient-centered care.
Effective strategies to change these policy barriers start with support for the Home Health Planning and Improvement Act of 2019, introduced with bipartisan support into the U.S. Senate as S.296 and the House as H.R. 2150. Write your legislators, visit members of Congress and ask them to support this legislation, or if they have already signed on, thank them for their support. These bills can be tracked at https://www.govtrack.us/congress/bills/#find.
Other ways to make these necessary changes include sharing your stories regarding barriers to care and access by writing letters to the editor of your local paper, journals, or Andrea Brassard at the Center to Champion Nursing in America at AARP (e-mail:
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- Davis, P.A. (2018). Medicare: Insolvency projections. Retrieved from https://fas.org/sgp/crs/misc/RS20946.pdf
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- Francisco, T., DeCastro, T., Harrison, N., Mowry, D., Croke, A., Bicket, M. & Buechner, J. (2018). Nurse practitioner home-based primary care program improves patient outcomes. The Journal for Nurse Practitioners, 14, e185–e188. doi:10.1016/j.nurpra.2018.08.003 [CrossRef]
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- Home Health Care Planning and Improvement Act of 2019, S.296, 116th Cong. (2019). Retrieved from https://www.congress.gov/bill/116th-congress/senate-bill/296
- Kinosian, B., Edes, T., Davis, D. & Hossain, M.I. (2010, May13). Financial savings of home based primary care for frail veterans with chronic disabling disease. Presented at the American Geriatrics Society Annual Scientific Meeting. , Orlando, FL. .
- The Lewin Group. (2010). Individuals living in the community with chronic conditions and functional limitations: A closer look. Retrieved from http://www.lewin.com/content/dam/Lewin/Resources/Site_Sections/Publications/ChartbookChronicConditions.pdf
- The Moran Company. (2019). Medicare payment systems. Retrieved from http://www.themorancompany.com/expertise/medicare-payment-systems
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