Assessing cost effects of nursing-home-based geriatric nurse practitioners

Health Care Financing Review, Spring, 1990 by Joan L. Buchanan, Robert M. Bell, Sharon B. Arnold, Christina Witsberger, Robert L. Kane, Judith Garrard

Assessing cost effects of nursing-home-based geriatric nurse practitioners

Introduction

As recent demographic changes have increased the population requiring long-term care for chronic illness, nursing home care--especially the rapid increase in nursing home expenditures and the poor quality of care--has been the subject of considerable concern.

Evidence of the extent of the Nation's concern about nursing home care comes from the 1986 Institute of Medicine Committee on Nursing Home Regulation's final report. As one means to improve nursing home care, the Committee encouraged nursing homes to "employ specialty-trained gerontological nurses and encourage currently employed nurses to seek training in gerontological nursing" (Institute of Medicine, 1986). Difficulties in obtaining sufficient physician attention to nursing home patients were found in studies by Mitchell and Hewes (1986) and Willemain and Mark (1980). These findings suggest that more highly trained nursing professionals can make important contributions to improving conditions in nursing homes. The unwillingness of many physicians to visit nursing home patients is of particular concern as the average age of patients increases and the functional status of the nursing home population continues to decline (Institute of Medicine, 1986). Without proper medical attention, treatments for ongoing medical conditions may go unmonitored and new conditions may go untreated, possibly causing unnecessary hospitalizations or mortality.

One effort to improve the care provided in nursing homes and make that care more cost effective is the introduction of new health professionals to serve as intermediaries between physicians and nursing homes. One such program has involved the training and employment of geriatric nurse practitioners (GNPs).

In 1975, the Mountain States Health Corporation (MSHC) initiated a program to select and train as GNPs current nursing home employees who were registered nurses but did not necessarily have a bachelor's degree. In return for partial support during the training phase, GNPs committed to remain in the nursing home for at least 18 months after the completion of training. The MSHC GNP education program included a 4-month didactic section completed at a participating university and an 8-month preceptor period completed under the supervision of an approved physician, usually at the sponsoring nursing home.

A multidimensional, quasi-experimental approach was employed to evaluate the project. The RAND Corporation and the University of Minnesota School of Public Health undertook an evaluation of the MSHC GNP program. RAND performed the cost and use analyses, and the University of Minnesota was responsible for the analysis of quality of care and GNP employment issues. MSHC secured the participation of the nursing homes used in the evaluation and supervised data collection efforts in the field. The evaluation covered eight Western States and included data from the period 1977-86. Results from the cost component of that evaluation are reported here. Other parts of the evaluation show:

* Modest improvements in some measures of process of care (Kane et al., 1989).

* No consistent changes in health outcomes (Kane et al., 1989; Garrard et al., 1989).

* Higher satisfaction among families of patients in nursing homes with GNPs (Skay et al., 1988).

* A commitment by MSHC GNPs to careers in long-term care (Radosevich et al., 1990).

In a study of the patient management process, significant improvements for the GNP homes were found for six of eight tracer conditions; this is the most notable benefit of the program. Patients in GNP homes were also somewhat less likely than others to have been discharged to a hospital by the end of the study. In addition, limited positive effects were observed on 2 of 8 functional status measures, on 2 of 6 drug therapies, and on 5 of 18 nursing therapies (Kane et al., 1989).

An important part of the cost component of the study is an attempt to determine who benefits from this new program and who currently pays its costs. Nursing homes typically employ GNPs primarily to improve care to patients. Better patient care benefits nursing homes if they become more attractive, particularly to private-pay patients. However, this incentive has limited appeal unless nursing homes can increase the proportion of private patients relative to public patients, because occupancy rates in most nursing homes are already high. In theory, the additional training that GNPs receive may increase employment costs to these nursing homes, and the added costs may not be offset by the resultant increase in private-pay patients.

The benefits of better patient care within nursing homes may actually accrue more to third-party payers than directly to the nursing homes. If better patient care within nursing homes reduces the need for and use of medical services outside nursing homes, it may be appropriate for third-party payers to bear some of the costs of employing these new providers. At present, most third-party payers do not reimburse for patient care services delivered by GNPs working as nursing home employees. The Omnibus Budget Reconciliation Act of 1989 contains yet to be implemented provisions for the Medicare reimbursement of nurse practitioners working in collaboration with physicians to treat nursing home patients.