American Academy of Home Care Physicians
Promoting the art, science and practice of medicine in the home.

1998 Vol. 10 No. 2
Issn# 1049-0027

Nurse Practitioners In The Home:
Two Perspectives By:
C. Gresham Bayne, MD and Peter A. Boling, MD

Those of you who watched 60 minutes on April 19, 1998 might have come away from the segment on nurse practitioners a little confused about medical home care. We'd like to comment on some of the key issues from the perspective of physicians whose primary expertise is in the area of home care. This show attempted to create a controversy between the American Medical Association perspective and a Columbia University outpatient treatment center run entirely by nurse practitioners in an affluent section of Manhattan. The segment clearly gave the nurse practitioners a positive spin by emphasizing their use of housecalls, while portraying physicians as having stopped making housecalls years ago.

In 1998 there was a major new development: Medicare payment was authorized for housecalls made by nurse practitioners as long as they met State requirements for licensure and practice coverage. We would like to comment on the topic from two perspectives. Dr. Boling has run a medical home care program at the Medical College of Virginia with extensive use of hospital-based nurse practitioners and physicians for years. Dr. Bayne has championed the "Call Doctor Service," characterized by full-time housecall physicians supported with technicians and technology. Call Doctor recently began using nurse practitioners under the new payment rules.

AAHCP: "Doctors, why did you elect to use nurse practitioners in your private practices?"

Dr. Boling: I studied models that had been developed by others who worked in this field long before I entered it. In particular, I was intrigued by the program offered by the Urban Medical Group in East Boston. This program emphasized continuity of care, which I think is very important for this population, and made extensive use of nurse practitioners as key medical providers for nursing home and home care patients. The costs of employing nurse practitioners are less than the costs of employing physicians, and the nursing background is often better suited to many of the needs encountered in the chronically ill populations these programs usually serve.

Dr. Bayne: Although we have concentrated on a "acute care model" to meet the exigencies of a managed care future, we quickly learned that patients refused to let go of the housecall physician that manages their acute illness successfully at home. Nurse practitioners fill that extremely important void for the homebound patient between acute illnesses, which is better managed with a chronic care model. It is much more cost-effective to use nurse practitioners than board-certified specialists in making routine visits.

AAHCP: "The AMA spokesperson on 60 Minutes implied that quality may be sacrificed for the cost savings of nurse practitioners. What are the quality risks for your practices?"

Dr. Boling: I would stack my team of nurse practitioners up against most physicians and suspect that I would come out ahead in this type of practice. They handle the full gamut: new patients, follow-up visits,and acute as well as chronic care. It is vital that they talk with the physicians regularly, know their limits, and have support from the physicians by way of housecalls.

There is also a wealth of data from a variety of settings that demonstrate comparable quality of care when nurse practitioners are involved with physicians in medical practices. Particularly, there is data from the nursing home world that speaks to improved quality as a result of bringing nurse practitioners into the service delivery picture. My experience, and our patient satisfaction surveys, agree with these other sources. Of course, I have a group of nurse practitioners who are experienced, who like home care, and who are very capable. I would not attempt this endeavor without a strong team since these patients are very sick and I would not encourage a practice that lacked active physician involvement.

Dr. Bayne: The major risk would be the same as with any physician: having a clinician not recognizing the need for consultation. We minimize this risk by strict hiring guidelines requiring a background in home health and years of experience, as well as by refusing to allow nurse practitioners to see new patients, or unscheduled acute problems in the first place.

AAHCP: "What are the advantages that nurse practitioners bring to your service?"

Dr. Boling: The biggest value that the nurse practitioners add, beside costing less to employ, is that they bring nursing perspective, training, and skills that physicians often lack and that are very important in chronic care. I learn as much from them as they learn from me about differential diagnosis, pathophysiology, pharmacology, and other areas where physicians usually have more expertise.

Dr. Bayne: We are admittedly new to this model, as Medicare has only allowed payment for urban visits by NPs for four months now. However, it is clear that nurse practitioners with a background in home health have major advantages over the alternatives of not giving the care, or giving chronic care using physicians. One of our NPs told me recently that she loved the job because now she could do what she has always been doing, only now she can do it legitimately. She also appreciates the ability to "finish the job" and write the prescriptions, phone in the home health orders, etc.

It is clear to me that NPs can perform a host of value-added services that physicians typically overlook in our attention to the "disease state" mode. They are more likely to retain the confidence of many patients who fear wasting the doctor's time, or fear that the doctor will place them in a nursing home. Our NPs are generally more sensitive to the social context of disease, and will spend more time talking through a patient's reaction to a medical decision. Finally, NPs are, in fact, nurses and will attend to many of the important issues such as skin care and preventive medicine.

AAHCP: "Well then, what are the problems with nurse practitioners?"

Dr. Boling: The biggest one is that there are not enough who are interested in or trained to work in this field of chronic care. There is also an important historical role definition issue: some of my physician colleagues often do not easily accept advice, referrals, or information from the nurse practitioners on our team. This results in some "re-work" since the same physicians are usually more receptive to the same input when it comes directly from me. The NPs on our team have some frustration over this "second class citizen" treatment.

Dr. Bayne: I don't see any problem that cannot be assigned to a simple "turf battle" over patient control issues, and hence are irrelevant to our practice. However, the introduction of a clinically-staged response to care in the home does test our system of triage. We have spent hundreds of man-hours and significant dollars on perfecting an algorithm-based triage system designed to place the patient's needs first and direct them to a 911 approach, a physician housecall, or a telephone order as appropriate.

Now, we have to incorporate an entirely new function with defined limits for triage so that doctors are not used inefficiently and nurses are not put in a critical care situation. Since our system is designed to meet all clinical problems except those that are immediately life-threatening, we will have to refine our Dispatch and Triage Manual somewhat.

AAHCP: "How do the nurse practitioners relate to the home health nurses?"

Dr. Boling: Most of the nurse practitioners I have employed in our program over the years have been home health nurses before they became nurse practitioners, so they are sensitive to the needs of the home health nurses. For the most part, the interactions are very collegial and positive. Occasionally you encounter a situation where a nurse doesn't want to take orders from another nurse. This usually happens when they disagree about what needs doing, or when the home health agency nurse is herself very experienced and confident of her position. This has not been a big problem.

Dr. Bayne: In our corporate center in San Diego, agency competition is so tough I really worried about a perception by home health agencies that we were "invading their turf." In fact, we are now hearing that we have better service since the doctors can be released for the urgent calls more easily, thereby keeping the patient at home where everyone wins. In addition, it seems clear in our early roll-out of this model that the nurse practitioners provide better preventive medical approaches and "bonding" with the Call Doctor Service. This prevents further fractionation of the system when someone gets suddenly unstable.

AAHCP: "You both seem to have a lot of respect for nurse practitioners. Who teaches whom at your Staff Meetings?"

Dr. Boling: We teach each other. I touched on this earlier and have little to add. My strength is medical knowledge and experience in making decisions in complex situations where a lot is at stake. The nurse practitioners bring their own unique strengths. We both learn.

Dr. Bayne: One of the attractions of home care to me is the relational aspect of a health care team. When I flew with LifeFlight, the critical care nurse was clearly better at certain things than I was, although my clinical judgment certainly remains at a higher level of education and experience. In home care, my biggest frustration has been with the federal policies precluding the close interaction of doctors and nurses in caring for sick patients. Although our NPs don't provide home health in the conventional sense, they do provide a nursing perspective that is an important complement to the total clinical picture.

AAHCP: "How do the doctors and nurse practitioners communicate?"

Dr. Boling: Our approach is pretty old fashioned. We see each other most days. Often this occurs in the later part of the afternoon when most of the team members are in the office. We also have a scheduled weekly meeting that is very important for our team. When something urgent is happening, the usual method is pagers and mobile phones. I am also experimenting with electronic mail for non-urgent matters and we see the need to develop an electronic patient record. There are a wealth of new information technologies that are going to radically change this aspect of how we communicate in the near future.

Dr. Bayne: We tend to seek high tech solutions to this major problem. Currently, we are doing one thing and developing another. The first thing we did was purchase a digital radiophone system so each clinician is one button away from all others during working hours. The NPs will simply scroll through the menu of physicians for the relevant one and push to talk. We can then have a "curbside consult" over patient care on a timely basis. Since the signal is rolled over between various frequencies, some privacy is provided, but it is not complete.

The second solution to the mobile communications problems lies in our development of the electronic medical record. We are in the third and final stage of developing the complete web-enabled charting, communications and billing systems that is obviously going to be the critical product for quality care in the home. All of us should be able to access the medical records anytime, anywhere! By customizing this charting system for the care of the homebound elderly, we can factor in such unique issues as trend analysis of the mental status exam, ADL score, or Beck Depression Index in the caregiver, for example. I might add that one of the distinct advantages Dr. Boling has is an office-based environment where the clinicians see each other regularly. The efficiencies of our entirely-mobile system and its concentration on staffing in the field limit this communication opportunity.

AAHCP: "Doctors, you both seem quite supportive of the nurse practitioner's role in the advancement of home care. This physician perspective seems to contradict the competitive one portrayed by 60 minutes. Any final comments?"

Dr. Boling: There is bound to be some competition as this picture evolves. There are a variety of different views about this issue among nurse practitioners and among physicians. Nurse practitioners have had a difficult time gaining acceptance and battling through numerous hurdles, many created by physicians, over the past decades. I am hopeful that we can set some of this political and historical baggage aside and move forward together in the creation of better models for patient care.

Dr. Bayne: I believe this was an older show first aired a year ago. Not only is medicine moving too rapidly to allow year-old news to be accepted, but in my practice this controversy simply doesn't exist. I would add a comment about the nurse practitioner portrayed in the 60 Minutes segment as making a housecall to the office of an elderly judge with a sore throat. Depending on your perspective (health care payor vs. productivity by the judge), this "housecall" might be considered inefficient. If the NP billed Medicare for this "housecall," one might even be concerned about fraud and abuse. This is an extremely complex area of healthcare law, and it would be difficult to do the subject justice in a few seconds out of sixty minutes. We do need to start thinking "out of the box" and designing health care systems that better meet the needs of our changing population and society.