Transcript TITLE HERE - American Academy of Home Care Medicine

Panel Discussion:
NP, PA, and Social Work
Practice: Roles and
Opportunities in Population
Health Management
Moderator:
Barbara Sutton, MSN APRN ACHPN
Panelists:
Deborah Wolff-Baker, MSN ACHPN FNP-BC
Tammy Browning, PA-C
Maureen Ryan, MSW LCSW
Faculty Disclosures
• Browning – no relevant disclosures
• Ryan – no relevant disclosures
• Sutton – no relevant disclosures
• Wolff-Baker – no relevant disclosures
Objectives
• Define important clinical competencies APN,
LCSW, and PA contribute to high-functioning
home based primary and palliative care teams
• Illustrate the role of each profession in
improving experience of care, improving
quality of care, and preventing unnecessary
costs in the home-limited population
• Describe variation by geography and discipline
in scope of practice and regulatory
considerations.
Importance of the
Interdisciplinary Team
• Each profession brings a different perspective
on patient assessment and treatment that
complements and enhances the team
• Each state has different practice regulations
• PA
• APRN
• LCSW
Nurse Practitioners
in Home Based Care
Deborah Wolff-Baker, MSN ACHPN FNP-BC
Northern California Medical Associates
[email protected]
Who is a Nurse Practitioner?
Education & Training
• Master’s or doctoral degree in Nursing
• Advanced clinical training with a minimum of 500 advanced practice clinical hours
• Initial RN preparation which includes 1200 or more clinical hours for BSN degree.
• Most NP programs also require a minimum of 2 years RN work experience prior to
admission to the NP program which adds another 2000 hours clinical experience.
Qualifications
• Rigorous national certification with re-certification process every 5 years with CE
including pharmacology and other professional development requirements
• Periodic peer review, clinical outcome evaluations
• Adhere to a code for ethical practices, continuous education and professional
development.
• Lead and participate in professional and lay health care forums, conduct research
and apply findings to clinical practice.
Services
Practice in primary care, acute care & long-term care settings, emphasizing whole
person health and well-being while focusing on health promotion, disease prevention,
health education and counseling. Autonomously and in collaboration with other health
care professionals, NPs provide a range of primary, acute & specialty health services
including:
• Ordering, performing and interpreting diagnostic tests such as lab work and x-rays.
• Diagnosing and treating acute and chronic conditions
• Prescribing medications and other treatments
• Managing patients’ overall care
• Educating & counseling patients on disease prevention, lifestyle and health
promotion.
Mission:
NCMA Home Based Palliative & Primary Care is an NP run practice
designed to meet the palliative, preventative and Primary Care
needs of Sonoma County’s frail elderly population. Care is provided
in the home setting where the medical and the social meet.
Goals:
1.
2.
3.
4.
5.
To improve Access to care for Sonoma County’s frail elderly by
providing Palliative, Primary, Transitional care and
comprehensive chronic disease management to patients, age
55+ who would otherwise find it difficult to access integrated,
coordinated medical services
To extend community survival
To clarify goals of care and Advance Directives
To reduce overall healthcare costs by preventing duplication &
overuse of healthcare resources, preventing hospital
admissions, re-admissions or by shortening LOS; assuring
care is consistent with patient & family values through the
prevention of unwanted or futile care.
To improve health, well-being and QOL.
Practice
• NCMA Structure: Independent Practice Association type
model
• Collaborating MD does not make House Calls
• One NP – Shared call weekends and after hours with LTC
on-call group
• Panel of approximately 50 fragile homebound patients
• Most patients are Dual Eligible
• Visits average every two months; weekly + with transitional
care
• Based on “Medical Necessity”
• NP may assume Primary Care Provider status for patient or
may report back to PCP within NCMA
• Patients are seen in a variety of settings: Private Homes,
Senior Living Apartments, Low Income Senior Complexes,
Assisted Living & Board and Care Residences, Assisted
Living Dementia Facilities, and Group Homes
Uniqueness of Practice
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•
•
•
Independent Practice Association (IPA) – type Model
Older adults/chronic disease management
Palliative & Primary Care
NP continues as PCP even after making a Hospice referral
• Referrals to Home Based Primary Care Program come
from:
• MD Offices (both NCMA and others)
• Home Health Agencies and Hospices
• Council on Aging
• Hospital Case Managers/Discharge Planners
• Self Referral
• Assisted Living Facilities/Board and Care Domiciles
and Skilled Nursing Facilities
• Word of Mouth
Collaboration
• Dr. Timothy Gieseke – Collaborating MD
• Other House Call Specialists
• Podiatrist
• Geriatric Neuropsychologist
• Geriatric Psychiatrist
• Various Specialists – Cardiology, GI, Ortho, Surgery
• Academic affiliation: RN to BSN, FNP & Health
Navigator Certificate students
• Home Health Agencies and Hospices
• Sonoma County Department of Adults and Aging
• APS, MSSP, IHSS, Linkages
• Imaging, Spirometry, BMD, Doppler, Holter
monitor, EKGs
• Laboratory
• DME companies
Dollars and Cents
Departments:
• Coding and Billing
• Credentialing
• Human Resources
• Information Technology and EMR
• CEO & Other Ancillary Support
These resources are utilized by all practices within NCMA including House
Calls.
Finances and Reimbursement (For Profit):
• HMO Contracts
• Traditional Fee for Service
• Medicare and Medi-cal (Medicaid)
• Private Insurances, Supplements, TriCare, etc.
All billing is done by NCMA billers.
Barriers to Nurse Practitioner
Practice
• Lack of standardized NP Scope of Practice (SOP) from State
to State – or even within a State due to differences in individual
Practice Protocols leads to misunderstandings and confusion
related to what a Nurse Practitioner is able to do.
• Full Practice States (22 + DC)
• Reduced Practice States (16)
• Restricted Practice States (12)
• California, for example, is a Restricted Practice State. Each
NP writes Practice Protocols and Standardized Procedures
specific to the practice setting, individual competencies, NP
and Physician preferences. All Advance Practice functions
beyond the RN role must be defined within these Practice
Protocols.
Other NP Barriers to Practice
• Unable on the Federal Level to sign for Medicare Certified Home
Health Orders – even in States with Full Practice Authority.
• Delays in providing care.
• Increased chance of poorly coordinated care.
• Costs associated with NPs having to pay an MD to sign the Home
Health Plan of Care (485).
• Home Health Planning and Improvement Act 2015
S.578 (Collins) and H.R. 1342 (Walden)
• In States without Full Practice Authority, NPs must have a signed
agreement with collaborating or supervising MD.
• Costs associated with paying for MD agreement / oversight
• What if the MD leaves the Practice, goes on vacation, dies?
• How many NPs can be supervised by one MD determined by
State as well as how far the distance between them can be during
patient visits.
Barriers to NP Practice Continued
• Insurance panels and reimbursements:
• Medicare reimburses NPs at 85% of Physician rates
• Many Insurance panels do not credential NPs
• Depending on the State, SOP, and Practice agreements,
some NPs cannot:
• Sign a death certificate
• Order a Schedule II narcotic
• Order DME
Important to know your State BRN regulations regarding NP Practice. This
will vary greatly depending on the State Practice environment.
In States with restricted or reduced SOP, written and signed Practice
Protocols/Standardized procedures must cover functions which would
otherwise be considered the practice of medicine.
Physician Assistants
in Home Based
Primary Care
Tammy Browning, PA-C
[email protected]
What is a Physician Assistant
PA is a nationally certified and state-licensed
medical professional.
PAs are concerned with preventing and treating human illness and injury by
providing a broad range of health care services under the supervision of a
physician. Their scope of practice can vary according to jurisdiction and healthcare
setting. Physician Assistant’s work may include conducting physical exams,
ordering and interpreting tests, diagnosing illnesses, developing treatment plans,
performing procedures, prescribing medications, advising on preventive health
care, and assisting in surgery.
Training and Qualifications
• Most PA programs are a masters level programs
(bachelor and certificate programs in past)
• 2,000 hours of clinical rotations
• Must pass a National Certifying Exam to practice
• Must retake/pass certification exam every 10
years (recently changed from every 6 years)
• Must complete 100 hours of CME every two
years
• Must maintain medical licensure in State of
practice
• Must have a Supervising Physician agreement
and scope of practice should be outlined and
correspond with the supervising physicians
scope of practice.
AAPA “Six Key Elements
Six Key Elements
1.
2.
3.
4.
5.
6.
“Licensure as the regulatory term
Full prescriptive authority
Scope of practice determined at
the practice level
Adaptable collaboration
requirements
Chart co-signature requirements
determined at the practice
Number of PA’s a physician may
supervise determined at the
practice level
How does a PA practice in Home Care
Medicine
• Integral part of team, enhances physicians
capacity to provide care to larger number of
patients
• Physician oversight is required, varying
regulations state to state
• PA vs NP vs Physician – what is the
differences in what PA’s bring
Barriers to PA Practice
• Medicaid Reimbursement – state dependent
and not recognized providers in all 50 states
• Limitations in number of PA’s a physician can
supervise (state by state differs)
• Certain states limit ability to prescribe controlled
substances
• Federal limitation on signing Medicare Home
Health Plan of Care or orders
• Patient view/understanding of PA role
• Physician view of PA and role in primary care
Resources
• American Academy of Home Care Medicine
• American Academy of Physician Assistants
www.aapa.org
• State Medical Association or Licensure board
• Provider Relations department of your state
Medicaid office
Social Workers in
Home Based Primary
Care
Maureen Ryan, MSW LCSW
What is a Social Worker?
Graduates of schools of social work who use
their knowledge and skills to provide social
services for clients. Social workers help people
increase their capacities for problem solving and
coping, and they help them obtain needed
resources, facilitate interactions between
individuals and between people and their
environments, make organizations responsible
to people, and influence social policies. Social
workers may work directly with clients
addressing individual, family and community
issues, or they may work at a systems level on
regulations and policy development, or as
administrators and planners of large social
service systems.
What is a Palliative Care Social
Worker?
• Counseling
• Education
• Planning
• Crisis
• Mediate Conflict
• Resources
• Advocacy
Licensure and Certification
• Licensure varies by state (some do not require
licensure)
• Exam
• Maintain CE’s
• Billing
• Only MSW or DSW can bill for services
• Must have two years experience
• ACHP-SW (2008)
Barriers to Practice
• Reimbursement rates
• Cannot bill in skilled nursing facilities or hospitals
• Services must be aimed at the diagnosis and
treatment of mental, emotional, behavioral illnesses
• Negative connotation with social worker
• New concept for many practices
Panel Discussion
Go to: 2Shoesapp.com/AAHCM2016
1. Click on the session you are in
2. Ask and vote on questions
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Annie is an independent 71 year old woman with
COPD living at home in the community. She
lives with, and provides care for her spouse, who
has a known dementia diagnosis.
Annie also has two out of state adult children
who visit twice a year. Annie is very private, and
has quietly been managing her own and her
husband’s finances, medications, and doctor
visits, not wanting to bother others for
assistance.
Annie was diagnosed with COPD last year, after
visiting her doctor for what she believed to be
bronchitis what wouldn’t improve.
Annie has been increasingly tired, is now
dependent on 4L 02. Annie has been a smoker
for 40 years and is currently smoking ½ ppd.
Comorbidities of:
• Pulmonary hypertension
• DM2
• Osteoarthritis
What Plan of Action Would a
NP, PA and SW have for Annie?
Current Medications:
Diagnosis List:
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Metformin 1000 mg bid
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COPD – O2 dependent
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Prandin 1 mg po ac tid
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Cough/SOB
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Valsartan 80 mg daily
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Fatigue
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HCTZ 25 mg daily
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Pulmonary Hypertension
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ASA 81 mg daily
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DMT2
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Advair 250/50 One puff bid
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OA
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Spiriva 18 mcg cap inhaled daily
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Tobacco use disorder
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Albuterol Unit dose ABT via in home nebulizer q 1h
prn wheezing
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At risk of Caregiver burnout
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Tylenol 650 mg tid
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Lack of social support/social isolation
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Multiple Vitamin with minerals daily
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Knowledge deficit related to disease management
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Vitamin D 2000 IU daily
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Possible medication non-compliance
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O2 as needed
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Unknown goals of care
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High use of hospital ER