By Megan Flaherty
Illustration by Eye Wire/Malcolm Garris
April 29, 1999

The demand for gerontologic nurse practitioners in nursing homes is growing as GNPs now care for long-term care residents who otherwise would not be getting the same level of care and attention. GNPs who work with long-term care residents or short-term patients who are transitioning between hospital and home say they consistently call on both their nursing perspectives and their specialized knowledge.

"Nurse practitioners have carved out a positive and specialized approach to health care in these institutional settings," said Judy Farness, MSN, GNP, RN, an assistant professor in geriatrics at Baylor College of Medicine in Houston. "NPs bring a unique perspective to residents. They come from a nursing point of view, but they have that piece of medical knowledge that enables them to intervene when something isn’t going well."

Emphasizing prevention

Geriatric Associates of America, a group of 10 nurse practitioners and nine physicians in collaborative practice in Baytown, contracts with long-term care facilities to care for residents, says Rhonda Hunsucker, MSN, GNP, RN. Hunsucker visits 12 facilities regularly, assessing patients and treating them for conditions such as pneumonia, skin ulcers, falls, and behavior problems.

Ten years ago, it was normal for a physician to visit a nursing home only every other month, Hunsucker said. Physicians still make their bimonthly visits, but nurse practitioners are now filling in the gaps, she said. "Hopefully, our presence in a facility at least twice a week instead of once every other month will keep people out of the hospital," she said.

GNPs conduct regular, thorough patient exams and take the time to focus on preventive care, Hunsucker said. A nursing home may only have one RN on staff, along with several LVNs and aides, she said. "One of our most important roles is to educate nurses on how to recognize changes in patients’ conditions so we can jump on problems early," she said.

In recent years, new state and federal laws governing NPs’ scope of practice have opened doors for gerontologic nurse practitioners, said Etoile Jessup, GNP, RN, who is responsible for a 10-bed inpatient hospice program at the Kerrville Division of the South Texas Veterans Health Care System.

A state law granted NPs prescriptive authority and a federal Medicare law allowed NPs to be reimbursed for nursing home visits at 80 percent of what physicians would receive. The use of GNPs instead of physicians is "financially advantageous" in a lot of healthcare settings, Jessup said. VA hospitals have traditionally used NPs "much more energetically" than the private sector, but "the private sector is catching up," she said.

Improving outcomes

Across the country, nursing homes are being used more as subacute care facilities to provide transitional treatment as patients are discharged faster from hospitals, experts say. "Nursing homes are taking very sick older patients post-surgery and caring for them in a subacute setting for a month and then discharging them to the community," said Neville Strumpf, PhD, RN, FAAN, associate professor and director of the gerontologic nurse practitioner program at the University of Pennsylvania School of Nursing. "These are very sick people with complicated cases. They need clinical management, case management, and teaching. This is a very important population the GNP can serve."

Nurse practitioners manage the care of such patients through a program launched by Kaiser Permanente Hayward in Northern California. "Our program is focused on short-term [nursing home] patients because their medical conditions are rapidly changing and on long-term patients with acute problems," said Liz Macera, MS, FNP, RN. Since the program began in 1991, Kaiser has found that nurse practitioners don’t decrease the lengths of stay in the facilities, but do decrease the rate of rehospitalization by nearly 10 percent, Macera said. Kaiser also found that the nurse practitioners increased referrals to specialists. NPs identify problems and facilitate their resolution earlier, she said.

"I find a lot of what I do might be termed case management," Macera said. "We guide people through the system and hook them up to resources." Macera works with patients recovering from surgeries, joint fractures, pneumonia, strokes, and other conditions, and coordinates treatment with pharmacists, dietitians, speech language pathologists, and physical therapists.

Strumpf said the care of geriatric patients is complex since they often have multiple chronic conditions and complicated psychosocial and environmental situations. "You need a team of people with a variety of skills focused on their needs," she said.

Only about 5 percent of people 65 and older live in nursing homes, Strumpf points out. Most live at home, and many live by themselves, she said. Opportunities for GNPs in home care, outpatient rehabilitation, and gerontologic clinical services—as well as in nursing homes—are enormous, she said. "Right now we’re not training even 10 percent of the geriatric-trained NPs or physicians that we are going to need," she said. "We’ve got all those baby boomers to think about."