Meshell Mansor, RN, APN-C, owner, Nurse Practitioner Professional Resources, a Turnersville, N.J.-based company that makes primary care house calls, said making those calls has shifted from a physicianís domain toward NPs. "Iíve been making house calls for about eight years," she said. "I belong to the Academy of Home Care Physicians. Initially, the membership there included very few nurse practitioners. Now, youíre seeing a lot."
Mansor makes house calls and also employs two primary care NPs and one wound care NP. "We started with 65 patients in 2008, and we have over 400 now," she said.
The house call business is thriving for NPs, and they say the role is ideally suited for the profession. "The aging population is increasing dramatically," said Mary Jo Vetter, RN, MS, NPC, vice president for clinical product development, Visiting Nurse Service of New York. "Iíve heard it called the 'gray tsunami,í and nurse practitioners are in a wonderful position to support the elderly, especially, to age in place."
Hospitals also are among the mix of employers for NPs in home care. Aleksandra Zagorin, RN, MSN, ANP-C, GNP-C, works at Maimonides Medical Center, Brooklyn, for the Home Medical Care for the Elderly program. She provides primary care house call services in South Brooklyn.
"We, as nurse practitioners, are able to deliver a level of care that may not be possible in the office setting," she said. "The major advantage in delivering primary care in patientsí homes is the ability to evaluate their living conditions and identify environmental hazards. We look at the environment for risk of falls. We meet with neighbors, family members or other members of the caregiver team, and are able to evaluate the social context of the patient."
That holistic approach to care makes NPs a natural fit. "You get a personal, up-close, intimate relationship with the patient," Mansor said. "You walk in and look at the family photos. You sit at the kitchen table. There is a lot of education that we can do in the home. We can pull something out of the freezer Ö and I can teach them how to read the food labels on items they have."
VNSNY identified gaps in care during its long history of providing care in the home, Vetter said.
"Sometimes [a gap] happens because the patient doesnít have a primary care provider or someone is unable to get to their primary care provider," she said. "Other times, people have five specialists and have no primary care provider. So, in the provision of home care, it became apparent that patients sometimes need a primary care kind of focus to string all of those services together."
In order to have NPs function at full scope of primary care practice, VNSNY created the professional corporation Esprit Medical Care, a home-visiting, multidisciplinary practice. Among the providers at Esprit are NPs, physicians, licensed clinical social workers, registered dieticians and certified diabetes educators. About 60 of the 90 providers are NPs, Vetter said. The NPs who make house calls say their patients tend to be so sick that they might not otherwise get the care they need to remain at home safely. Mansor said about 90% of her clients are homebound elderly Medicare recipients. Typically, patients have multiple diagnoses and often have behavioral health problems, complex family care and end-of-life issues.
NPs face hurdles in being able to provide the full spectrum of primary care in the home. Advanced practice nurses can write prescriptions for medications but cannot sign home care certifications. Those have to be cosigned by a collaborative physician.
"I think that even though we are recognized more than we used to be, autonomy is still a major professional issue," Zagorin said.
Barbara Maidhof, RN, BSN, MPA, assistant vice president, clinical operations, North Shore LIJ Homecare Network, Westbury, N.Y., said the fact government regulation does not recognize NPs is an issue for employers.
"Iíve never had an NP work in home care, [but if I did] they could sign only as a registered nurse because there is no recognition for their higher level," Maidhof said. "We do have a hospitalist program here and NPs who go out from that program to see some of the homebound patients. There is interaction between those NPs and my staff. However, they cannot write the orders for home care. It has to go back to the physician in the house calls program."
What Vetter calls a "turf war" between physicians and NPs has yet to change.
"Because government regulations say you cannot have the NP sign the order, the physician is signing the order more for regulatory purposes," she said. "Sometimes, the NP is the only one who has really seen the patient."
While NPs are required to access collaborating primary care physicians, their best efforts to refer homebound patients to specialists donít often pan out, according to Mansor.
"We try very hard to work with the family, to see if there is any way to find transportation," she said. "Unfortunately, Medicare does not provide transportation for the homebound elderly. So, we manage the care the best we can and, if it gets too difficult, we have to send them through the emergency room."
Hospital admission is another hurdle for NPs.
"We really need to find a way to improve communication between the house call practice and the hospital," Mansor said.
Reimbursement is not so much an issue now, but it could be, according to Mansor. Talk of reducing Medicare reimbursement with healthcare reform could force Mansor to lay off staff, she said.
For now, Mansor is averaging five to eight new patients a week and envisions her company will expand its NP staff and service area. The skyís the limit, Vetter said, when it comes to the growth potential of NPs working in the home.
"We are constantly recruiting NPs to work with the practice because there is a lot of value across the state, and even nationally, for nurse practitioners to care for patients in their homes, whether they are disabled or homebound because of medical illness or end of life," Vetter said.
Lisette Hilton is a freelance writer.
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