SALT LAKE CITY — A nurse-practitioner model can overcome regulatory and reimbursement barriers to the delivery of palliative care to patients in nursing homes, according to Dr. Jeanne Elnadry, medical director of the Hospice of Yuma (Ariz.).
“These chronically ill and terminal patients are among the most vulnerable in our society, and they have lots of needs that are not adequately addressed,” Dr. Elnadry said at the annual meeting of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association.
“Nurse practitioners can help to fill some of that void if they have adequate training and desire,” she added.
In 2004, Dr. Elnadry—along with Peggy Edwards, a nurse practitioner certified in geriatrics and palliative care management—began developing a modest palliative care service that provides consultations to Yuma's four nursing homes, which have a total of 450 beds.
Their goals were to decrease utilization of the local hospital's emergency department, to reduce hospitalizations, and to provide better and more comprehensive care to nursing home residents, said Dr. Elnadry, who also provides palliative care consultations at the Yuma Regional Medical Center.
“Palliative care in nursing homes is for patients who, for some reason, cannot receive hospice care even though they have a prognosis of under 6 months,” Dr. Elnadry said in an interview. It's also for patients who will most likely live longer than 6 months but have a life-limiting or highly symptomatic condition, or for patients who have a condition such as Alzheimer's disease who may require palliative care for an extended period of time until they are eligible for hospice care, she said.
Many nursing home patients have terminal diagnoses with prognoses of much less than 6 months, and would benefit from the types of services available in hospice, such as social work services, the assessment and management of complex symptoms by registered nurses, and bereavement support, she said.
The role of the palliative care nurse practitioner is to provide consultations (on a physician's order), to communicate directly with the primary physician, to conduct family meetings as necessary, to write symptom management orders, and to perform follow-up for symptom management and decision making, Dr. Elnadry explained.
She noted that among the challenges to the provision of palliative care in nursing homes are several myths: that such care is strictly for the end of life; that Medicare will not pay for skilled and palliative care simultaneously; that Medicare skilled beds are only for patients who are able to participate in rehabilitative care and are going to “get better”; and that palliative care services by physicians, nurse practitioners, and physician assistants is not reimbursable.
One obstacle is that Medicare will not pay for hospice care and skilled nursing care in a nursing home at the same time, and there is no payer source for palliative care interdisciplinary teams in nursing homes. Dr. Elnadry—who bills her visits under Medicare Part B, which doesn't cover all expenses—said that the Centers for Medicare and Medicaid Services needs to address the needs of these very ill nursing home patients.
“Because there is no adequate system for reimbursement for the time required for complex consultations and family meetings, some programs rely on grants, but you can't run a health care system on grants. We didn't obtain a grant and [thus] have to cover our costs through billing. That's important because a nurse practitioner costs less than a physician, so if the nurse sees enough patients, then the billing may cover her costs,” Dr. Elnadry said in an interview.
Ms. Edwards noted that “ours is a heavily regulated industry with an unbelievable burden of rules and regulations that weigh against palliative care in nursing homes.” There is no incentive to accept a patient into a nursing home if he or she is considered “terminal,” she added.
The first step in implementing a palliative care service in the nursing home is to identify those with the authority to help you succeed, Ms. Edwards explained. “Develop your champions, including the administrator, the head of finance, the minimum data set coordinator, the director of nursing, and perhaps your director of social services. These are key people with clout.”
Ms. Edwards recommended targeting appropriate patients for palliative care, such as patients with aggressive advanced disease and a poor prognosis or those who have functional decline despite receiving physical therapy rehabilitation; patients who make frequent trips to the hospital; and patients with acute, chronic, or uncontrolled pain.
“Include advance care planning with advance directives, and address psychosocial and spiritual concerns with patients and their families, and with caregivers and staff,” she said.