APRNs play critical role in providing quality care to homebound seniors.
The author takes healthcare to the patient and, in collaboration with other disciplines, provides comprehensive care at lower cost.
For me, as with most people, going to work every day requires motivation. But soon after seeing my first homebound patient of the day, I am reminded that, without my help, these seniors would have a tough time receiving the healthcare they need. If it weren’t for me, they might have to be transported to the emergency department or be hospitalized. In the United States, relatively few physicians and nurse practitioners make house calls. Those who do need to plan carefully and deal with bad weather, road hazards, and other problems.
Collaboration is vital. Sustaining a viable house call practice requires coordination among multiple healthcare disciplines. In my practice, I work closely with physicians, advanced practice registered nurses (APRNs), home health nurses, and other members of the healthcare team, including physical and occupational therapists, pharmacists, and social workers. Collaborating with these providers enables me to offer more comprehensive care.
Nursing bridges EBP gaps
Overall, evidence-based practice has become the new standard for healthcare disciplines, including nursing. More and more nurses are participating in EBP initiatives, whether through research, education, or practice. Indeed, of all the healthcare professions, nursing is perhaps the only one that has bridged research (through PhD-prepared nurse researchers), education (through EdD-prepared nurse educators), and translation of evidence into practice (through DNP-prepared practitioners).
As nurses become more skilled in analyzing research, gathering evidence, and applying it to practice situations, the body of nursing knowledge continues to grow. As a result, nurses are increasingly stepping up to the responsibility of not only managing individual and family care but also responding to the need to address population health. One example of nursing’s increasing involvement in advancing population health is its participative role in policy and advocacy for vulnerable homebound older adults. Policies that promote improved access enable nurses to more efficiently provide the comprehensive care this population group deserves.
APRNs need full practice authority
The 2010 Institute of Medicine report titled The Future of Nursing: Leading Change, Advancing Health asserts that nurses should practice to the full extent of their education and training. [The National Academies’ Institute of Medicine was renamed the Health and Medicine Division in 2016.] Twenty-three U.S. states mandate full-practice authority for advanced practice registered nurses. Even though APRNs in these states have full-practice authority, full practice is still restricted somewhat on the federal level, thus reducing access and adding cost to healthcare. One of those barriers is in the area of home health services. APRNs should be allowed to certify patients for Medicare payment of home health services. Current regulations, however, do not allow it.
The Future of Nursing: Campaign for Action, which is backed by AARP, AARP Foundation, and the Robert Wood Johnson Foundation, supports changes that will allow APRNs to certify for home health services. This means that more Americans, especially those who are homebound and vulnerable and those who live in rural and other underserved areas of the country, will have access to high-quality, affordable healthcare.
This change also provides interprofessional benefits for the healthcare team. Authorizing APRNs to determine client eligibility for home health services and prepare required documentation reduces paperwork and relieves physicians of the task. Most importantly, allowing APRNs to certify patient clients provides for more efficient delivery of home health services and expedites treatment.
In the patient’s best interest
APRNs, particularly those serving homebound seniors, act as bridges in providing care for this growing population because many older adults are unable to travel to see primary care providers. In some states, APRNs have to wait for signatures from collaborating physicians on home health certification documents, thus delaying delivery of care. It is in the patient’s best interest for the provider who makes the house call to also be the provider who certifies the need for home health services and communicates those needs to the Medicare-certified home health agency.
As part of my Doctor of Nursing Practice (DNP) project, I investigated use of house calls by APRNs as a method for reducing 30-day unplanned ED visits and hospital readmissions. I found that homebound seniors benefit from an APRN visit when transitioning from hospitals or skilled nursing facilities to home. APRNs who have prescriptive authority in the United States can reduce polypharmacy significantly. I also found that more than half of patients seen during transitional house call visits need a prescription at the time of the visit and that the majority of them don’t see their primary care provider until at least 14 days after discharge. Reducing unplanned 30-day readmissions can save Medicare up to $15,000 per readmission. Compare this to an average of $180 per APRN house call during care transitions. These numbers are highly significant because healthcare costs have risen from $6.2 billion in 1997 to $2.8 trillion in 2012 and continue to increase.
Focusing on comprehensive healthcare
Every day, APRNs like me who focus on house calls for homebound seniors collaborate with a multidisciplinary team to provide healthcare access and comprehensive care. Authorizing APRNs to certify for home health services is a significant step toward improving access to care for homebound patients and their families.
Nurses, the most trusted professionals, are caring scientists who improve the health and safety of those they serve. Whether as school nurses, bedside nurses, educators, practitioners, legislators, or other leaders, nurses play a significant role in improving world health. The patients, families, and communities in our care rely upon us. The nursing profession must respond to this call for advocacy locally, nationally, and worldwide. RNL
Ron Billano Ordona, DNP, practices at Senior Care Clinic House Calls in Lincoln, California, USA. He is also a member of the clinical faculty at the Betty Irene Moore School of Nursing at the University of California, Davis and at Boise State University School of Nursing in Boise, Idaho, USA.
Editor’s note:
Ron Ordona will present “NP-Led Medical House Call in Transition of Care Reduces Polypharmacy” on Saturday, 21 July 2018, at Sigma’s 29th International Nursing Research Congress in Melbourne, Australia. Register here for congress.