Nurse Practitioner Model
Abstract Advances in medicine have increased the life expectancy from 45 to 78 years of age in the last century. As the population ages, so does the number of chronic illness and the need for specialized end-of-life care. With the current shortage of trained hospice care providers, the push for utilization of nurse practitioners in this area of medicine is being looked at as a possible solution. Efficacy of a nurse practitioner led model of care has been demonstrated in the limited amount of studies done in recent years and shows promise of a solution to the shortage. The hospice model of care focuses on improving quality of life rather than prolonging it, and holistically embraces the principles of dying with comfort and dignity. Removing
…show more content…
barriers of care provided by nurse practitioners is one step in improving patient outcomes and patient satisfaction.
Role of the Nurse Practitioner in Hospice Care
Hospice has become a vital part of end of life care over the last several decades due to the aging population.
Although hospice has been around since the 1960’s it still faces many challenges such as increased work load, a lack of hospice trained healthcare providers, and hospice Medicare requirements. Due to these issues, the role of the nurse practitioner has become increasingly more important to hospice care.
Hospice can be described as a philosophy of care that focuses on the palliation of a terminally ill patient’s symptoms while providing emotional and spiritual support for them and their family (Meirer, McCormick, & Lagman, 2015). The hospice model of care focuses on improving quality of life rather than prolonging it, and holistically embraces the principles of dying with comfort and dignity. This model uses an interdisciplinary team to develop an individualized plan of care that addresses all aspects of care and is based on the patient’s goals and cultural values (Meirer, McCormick, & Lagman, …show more content…
2015).
Hospice was first introduced in 1948 by a physician named Dame Cicely Saunders. In 1963, Saunders introduced the idea to the United States during a lecture at Yale University. Saunders eventually went on to create the first hospice facility named St. Christopher’s Hospice in London in 1967 (The National Hospice and Palliative Care Organization, 2014). In 1978, the United States Department of Health, Education, and Welfare task force reported that the hospice movement was a means of providing humane care for the terminally ill while reducing healthcare costs. By 1993, hospice care became a guaranteed benefit under President Clinton’s health care reform and in 2009, The National Hospice and Palliative Care Organization (NHPCO) set new standards of practice for pediatric palliative care (NHPCO, 2014).
Currently, hospice is thought of as a continuum of care that services more than 1.5 million people (NPHCO, 2014). Hospice services are now provided by various hospital systems, home health agencies, and nursing homes. The services provided include management of pain and other end of life symptoms, assistance with the emotional, psychosocial and spiritual aspects of dying, and counseling to surviving family members and friends (NPHCO, 2014).
The regulation of hospice varies on the federal, state, and local levels. On the federal level, the Department of Health and Human Services and Centers for Medicaid Services (CMS) are the agencies that regulate hospice. In 2008, Medicare and Medicaid initiated the Hospice Conditions of Participation. These requirements set new standards of care that reflected the unique needs of hospice patients. These standards required that all patient care areas be set up in a way that would provide for comfort, dignity, and privacy and that treatment must provide for symptom management, as well as respite purposes (Federal Register, 2008). Furthermore, the hospice agency must conduct and document in writing an individualized comprehensive assessment that identifies the patients need for hospice and include any physical, psychosocial, emotional and spiritual care needed (Federal Register, 2008). This comprehensive assessment must also include a plan of care that specifies services and treatment necessary to meet the patient and family’s goals and cultural values (Federal Register, 2008).
On the state level, The Department of Aging and Disability Services (DADS) and the Home and Community Support Services Agency (HCSSA) are responsible for regulation and licensure for hospice facilities in Texas. Home health agencies with hospice service designation or any other agency that identifies itself as a hospice must be fully licensed and certified by these agencies in order to be eligible to participate in the Medicare Hospice Program (CMS, 2011). Hospices must meet all conditions of participation to become licensed and allowed to participate in the Medicare hospice program. As for the local level, there are currently no agencies that regulate hospice care in the Rio Grande Valley.
One of the greatest obstacles for hospice is the lack of workforce with expertise in palliative medicine. More specially trained providers are needed due to aging population, shortage of hospice trained physicians, and high work load demands. Also, the recent increase of hospice programs along with Centers for Medicare and Medicaid Services requirement for a face to face visit by a physician in order to recertify a patient’s eligibility for hospice service has led to an even greater discrepancy between workforce capacity and clinical need (Meirer, 2011). Due to these issues the role of the nurse practitioner in this sector has become increasingly more important.
Nurse Practitioners have the skill set and autonomy to assess, plan, implement, and evaluate palliative care interventions which makes them perfect for the hospice care setting. Nurse practitioners can also play a vital role in palliative care consults, providing timely treatment interventions, and providing education to patients and family members. A recent study showed using nurse practitioners as hospice providers led to improved end of life outcomes, lowered healthcare costs, and improved patient and family satisfaction (Fox, 2013).
The key components of palliative medicine include clinician–patient communication, psychosocial, spiritual, and bereavement support (Heinle, McNulty, and Hebert, 2014). Although these skills are not traditionally included in a physician’s curriculum, they are rooted in the culture of nursing. For this reason, the education and experience of nurse practitioners make them ideally suited for hospice care (Heinle, McNulty, and Hebert, 2014).
Financially, hospice programs have also been shown to reduce healthcare costs while still maintaining a high quality of care. Although the seriously ill only account for about a tenth of all patients in the United States, they are responsible for well over half of the nation’s healthcare costs (Meirer, 2011). Hospice programs have the ability to reduce healthcare costs by preventing unnecessary hospitalizations, readmissions, and emergency department visits for these types of patients. Patient satisfaction has become one of the founding elements of our healthcare reform. Hospice and palliative care have demonstrably shown that they have the ability to improve physical and psychological symptoms, family caregiver well-being, bereavement outcomes, and patient, family, and physician satisfaction (Meirer, 2011). This is achieved by addressing pain and symptoms that would have otherwise lead to unnecessary hospitalizations. Another way this is achieved is by meeting with family to establish clear individualized goals for managing their loved ones right to die with dignity. Palliative care is estimated to save $1.2 billion per year under the current use of service, increasing exponentially [$4 billion] if current hospice capacity was increased to meet the needs of six percent of hospital discharges nationwide (Meirer, 2011). The nature of dying has changed with the advancement of medical research and treatment, increasing the life expectancy from 45 to 78 years of age in the last century (Heinle, McNulty, & Hebert, 2014). This increased longevity of life has augmented the number of people living with chronic disease, noting that 90 million people in the United States live with at least 1 chronic disease, and an estimated 70% die from chronic disease such as cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), or dementia (Heinle, McNulty, & Hebert, 2014). Systematic reviews conducted comparing outcomes of care provided by nurse practitioners have time and time again demonstrated the efficacy of the care provided, as reflected by the higher patient satisfaction and lower re-admission rates by improving symptoms at the end of life (Heinle, et al, 2014). Although, nurse practitioners have made leaps and bounds in hospice and palliative care, they are still limited in its capacity to provide unrestricted care for patients needing hospice or palliative care services. Currently, Medicare rules and regulations do not allow advanced practice nurses to sign certification documents to allow patients to receive these services, even though the patient can choose to have a nurse practitioner as their primary provider (Brassard, 2012). Requiring a physician to sign off the nurse practitioner recommendations for home care services may delay care and result in hospitalizations that could have been avoided. The delay in care caused by this clause can be detrimental, especially for the homebound patient in a rural area where access to physicians are limited (Brassard, 2012). The estimated cost savings to Medicare are about $129.2 to $309.5 million a year in allowing nurse practitioners to sign the certification letter for home and hospice services (Brassard, 2012). Hospice and palliative medicine is greatly limited in the area of research, although the potential exists.
Information regarding the quality of hospice programs insufficiently show the true potential and benefit of a nurse practitioner led model. One study evaluated the nurse practitioner based model of specialized palliative care in the home environment in an effort to test the sustainability and evaluation of feasibility of nurse practitioner services (Bookbinder, Glajchen, McHugh, Higgins, Budis, Solomon, Homel, Cassin, & Portenoy, 2011). What her team discovered was the nurse practitioner led model generated an approximate 360% increment in hospice admission compared with the two years before the program, and the incremental surplus to the hospice program from these patients was determined to be approximately $1.875 million annually. Not only did the profit margin increase substantially, the comparison of the prevalence of distress at baseline and follow up showed statistically significant decrease in symptoms of pain, shortness of breath, weight loss, and difficulty sleeping (Bookbinder, et al, 2011). It was noted that at the end of the study, the hospice agency hired an additional four nurse
practitioners. The utilization of nurse practitioners has effectively demonstrated that positive patient satisfaction and cost saving measures can be implemented in the hospice care setting. With the push to remove the restrictions on requirements for physician sign-offs for services, the full impact of a nurse practitioner led model of care can be realized. The sustainability of these programs has been demonstrated in the few studies that have been completed, but more research is needed to prove the efficacy of nurse practitioners in hospice care. As the population ages, the need for hospice does as well. Removing the barriers to complete autonomy of care for nurse practitioners in hospice will eliminate delays in care and will allow the practitioner to effectively manage chronic illness, reducing the need for unwarranted hospitalizations.
barriers of care provided by nurse practitioners is one step in improving patient outcomes and patient satisfaction.
Role of the Nurse Practitioner in Hospice Care
Hospice has become a vital part of end of life care over the last several decades due to the aging population.
Although hospice has been around since the 1960’s it still faces many challenges such as increased work load, a lack of hospice trained healthcare providers, and hospice Medicare requirements. Due to these issues, the role of the nurse practitioner has become increasingly more important to hospice care.
Hospice can be described as a philosophy of care that focuses on the palliation of a terminally ill patient’s symptoms while providing emotional and spiritual support for them and their family (Meirer, McCormick, & Lagman, 2015). The hospice model of care focuses on improving quality of life rather than prolonging it, and holistically embraces the principles of dying with comfort and dignity. This model uses an interdisciplinary team to develop an individualized plan of care that addresses all aspects of care and is based on the patient’s goals and cultural values (Meirer, McCormick, & Lagman, …show more content…
2015).
Hospice was first introduced in 1948 by a physician named Dame Cicely Saunders. In 1963, Saunders introduced the idea to the United States during a lecture at Yale University. Saunders eventually went on to create the first hospice facility named St. Christopher’s Hospice in London in 1967 (The National Hospice and Palliative Care Organization, 2014). In 1978, the United States Department of Health, Education, and Welfare task force reported that the hospice movement was a means of providing humane care for the terminally ill while reducing healthcare costs. By 1993, hospice care became a guaranteed benefit under President Clinton’s health care reform and in 2009, The National Hospice and Palliative Care Organization (NHPCO) set new standards of practice for pediatric palliative care (NHPCO, 2014).
Currently, hospice is thought of as a continuum of care that services more than 1.5 million people (NPHCO, 2014). Hospice services are now provided by various hospital systems, home health agencies, and nursing homes. The services provided include management of pain and other end of life symptoms, assistance with the emotional, psychosocial and spiritual aspects of dying, and counseling to surviving family members and friends (NPHCO, 2014).
The regulation of hospice varies on the federal, state, and local levels. On the federal level, the Department of Health and Human Services and Centers for Medicaid Services (CMS) are the agencies that regulate hospice. In 2008, Medicare and Medicaid initiated the Hospice Conditions of Participation. These requirements set new standards of care that reflected the unique needs of hospice patients. These standards required that all patient care areas be set up in a way that would provide for comfort, dignity, and privacy and that treatment must provide for symptom management, as well as respite purposes (Federal Register, 2008). Furthermore, the hospice agency must conduct and document in writing an individualized comprehensive assessment that identifies the patients need for hospice and include any physical, psychosocial, emotional and spiritual care needed (Federal Register, 2008). This comprehensive assessment must also include a plan of care that specifies services and treatment necessary to meet the patient and family’s goals and cultural values (Federal Register, 2008).
On the state level, The Department of Aging and Disability Services (DADS) and the Home and Community Support Services Agency (HCSSA) are responsible for regulation and licensure for hospice facilities in Texas. Home health agencies with hospice service designation or any other agency that identifies itself as a hospice must be fully licensed and certified by these agencies in order to be eligible to participate in the Medicare Hospice Program (CMS, 2011). Hospices must meet all conditions of participation to become licensed and allowed to participate in the Medicare hospice program. As for the local level, there are currently no agencies that regulate hospice care in the Rio Grande Valley.
One of the greatest obstacles for hospice is the lack of workforce with expertise in palliative medicine. More specially trained providers are needed due to aging population, shortage of hospice trained physicians, and high work load demands. Also, the recent increase of hospice programs along with Centers for Medicare and Medicaid Services requirement for a face to face visit by a physician in order to recertify a patient’s eligibility for hospice service has led to an even greater discrepancy between workforce capacity and clinical need (Meirer, 2011). Due to these issues the role of the nurse practitioner in this sector has become increasingly more important.
Nurse Practitioners have the skill set and autonomy to assess, plan, implement, and evaluate palliative care interventions which makes them perfect for the hospice care setting. Nurse practitioners can also play a vital role in palliative care consults, providing timely treatment interventions, and providing education to patients and family members. A recent study showed using nurse practitioners as hospice providers led to improved end of life outcomes, lowered healthcare costs, and improved patient and family satisfaction (Fox, 2013).
The key components of palliative medicine include clinician–patient communication, psychosocial, spiritual, and bereavement support (Heinle, McNulty, and Hebert, 2014). Although these skills are not traditionally included in a physician’s curriculum, they are rooted in the culture of nursing. For this reason, the education and experience of nurse practitioners make them ideally suited for hospice care (Heinle, McNulty, and Hebert, 2014).
Financially, hospice programs have also been shown to reduce healthcare costs while still maintaining a high quality of care. Although the seriously ill only account for about a tenth of all patients in the United States, they are responsible for well over half of the nation’s healthcare costs (Meirer, 2011). Hospice programs have the ability to reduce healthcare costs by preventing unnecessary hospitalizations, readmissions, and emergency department visits for these types of patients. Patient satisfaction has become one of the founding elements of our healthcare reform. Hospice and palliative care have demonstrably shown that they have the ability to improve physical and psychological symptoms, family caregiver well-being, bereavement outcomes, and patient, family, and physician satisfaction (Meirer, 2011). This is achieved by addressing pain and symptoms that would have otherwise lead to unnecessary hospitalizations. Another way this is achieved is by meeting with family to establish clear individualized goals for managing their loved ones right to die with dignity. Palliative care is estimated to save $1.2 billion per year under the current use of service, increasing exponentially [$4 billion] if current hospice capacity was increased to meet the needs of six percent of hospital discharges nationwide (Meirer, 2011). The nature of dying has changed with the advancement of medical research and treatment, increasing the life expectancy from 45 to 78 years of age in the last century (Heinle, McNulty, & Hebert, 2014). This increased longevity of life has augmented the number of people living with chronic disease, noting that 90 million people in the United States live with at least 1 chronic disease, and an estimated 70% die from chronic disease such as cardiovascular disease, cancer, chronic obstructive pulmonary disease (COPD), or dementia (Heinle, McNulty, & Hebert, 2014). Systematic reviews conducted comparing outcomes of care provided by nurse practitioners have time and time again demonstrated the efficacy of the care provided, as reflected by the higher patient satisfaction and lower re-admission rates by improving symptoms at the end of life (Heinle, et al, 2014). Although, nurse practitioners have made leaps and bounds in hospice and palliative care, they are still limited in its capacity to provide unrestricted care for patients needing hospice or palliative care services. Currently, Medicare rules and regulations do not allow advanced practice nurses to sign certification documents to allow patients to receive these services, even though the patient can choose to have a nurse practitioner as their primary provider (Brassard, 2012). Requiring a physician to sign off the nurse practitioner recommendations for home care services may delay care and result in hospitalizations that could have been avoided. The delay in care caused by this clause can be detrimental, especially for the homebound patient in a rural area where access to physicians are limited (Brassard, 2012). The estimated cost savings to Medicare are about $129.2 to $309.5 million a year in allowing nurse practitioners to sign the certification letter for home and hospice services (Brassard, 2012). Hospice and palliative medicine is greatly limited in the area of research, although the potential exists.
Information regarding the quality of hospice programs insufficiently show the true potential and benefit of a nurse practitioner led model. One study evaluated the nurse practitioner based model of specialized palliative care in the home environment in an effort to test the sustainability and evaluation of feasibility of nurse practitioner services (Bookbinder, Glajchen, McHugh, Higgins, Budis, Solomon, Homel, Cassin, & Portenoy, 2011). What her team discovered was the nurse practitioner led model generated an approximate 360% increment in hospice admission compared with the two years before the program, and the incremental surplus to the hospice program from these patients was determined to be approximately $1.875 million annually. Not only did the profit margin increase substantially, the comparison of the prevalence of distress at baseline and follow up showed statistically significant decrease in symptoms of pain, shortness of breath, weight loss, and difficulty sleeping (Bookbinder, et al, 2011). It was noted that at the end of the study, the hospice agency hired an additional four nurse
practitioners. The utilization of nurse practitioners has effectively demonstrated that positive patient satisfaction and cost saving measures can be implemented in the hospice care setting. With the push to remove the restrictions on requirements for physician sign-offs for services, the full impact of a nurse practitioner led model of care can be realized. The sustainability of these programs has been demonstrated in the few studies that have been completed, but more research is needed to prove the efficacy of nurse practitioners in hospice care. As the population ages, the need for hospice does as well. Removing the barriers to complete autonomy of care for nurse practitioners in hospice will eliminate delays in care and will allow the practitioner to effectively manage chronic illness, reducing the need for unwarranted hospitalizations.