Why Advanced Practice RNs Could Be MVPs in Skilled Nursing Cost Savings, Care Outcomes

As nursing home staff continue to see a higher concentration of high acuity patients, advanced practice registered nurses (APRNs) may be the key to improving care outcomes and reducing hospital readmissions.

University of Missouri Sinclair School of Nursing Assistant Professor Alisha Johnson spent a year interviewing APRNs in Texas about their transition to the nursing home setting, digging deeper into their impact on improved decision-making and in turn resident health outcomes between 2019 and 2020.

APRNs have advanced training in pharmacology, diagnostics, lab work, blood tests, radiology, early illness detection and medications, Johnson said; this broad level of expertise helps APRNs make care decisions and improve resident health outcomes.

“They have that one-on-one relationship with a resident, assessing them and diagnosing issues and prescribing care, but they were also able to function on a facility level,” Johnson told Skilled Nursing News. “There’s a system training component that helps them see the bigger picture, not just the patient, but the environment that they live in, other determinants that impact their care and their health.”

Johnson found that existing nursing home staff often didn’t understand how an APRN could offer such beneficial expertise. Once they saw the APRN as a collaborator rather than a competitor in the reimbursement structure, outlook on the role changed.

Building the case for APRNs

Her research serves as a companion piece of sorts to a study evaluating the effectiveness of APRNs in the nursing home setting. The original $35 million MU program followed APRNs in 16 Missouri nursing homes over the course of five-plus years – more than $31 million in savings was estimated to have been achieved during those years as avoidable hospitalizations and emergency visits were reduced.

Professors at the University of Missouri were awarded an additional $200,000 grant from the Donaghue Foundation to further study the link between this role and care outcomes; original funding came from the Centers for Medicare & Medicaid Services (CMS).

Johnson and fellow researcher Tracie Culp Harrison’s qualitative research – Advanced Practice Registered Nurse Transition to Practice in the Long-Term Care Setting: An Ethnography – followed nine APRNs in five long-term care facilities.

Next steps to elevate APRNs

In order to further incorporate APRNs into the nursing home setting, Johnson suggested CMS and state agencies modify the reimbursement structure to encourage collaboration with APRNs, instead of “leaving them on the sidelines” or creating a competitive reimbursement environment.

She also called for the state to change a requirement that APRNs can’t provide assessments or write orders independently, instead having to work under a physician. Other states that don’t require such supervision have “just as good” health outcomes among their residents, according to Johnson.

Nurses and aides must await a care plan from a physician, who is often not present in the nursing home, she said. Delayed action leads to declining resident health outcomes and in some cases that costly and stressful trip to the hospital.

There are three times as many APRNs working in long-term care facilities compared to physicians, Johnson added; meanwhile, the number of physicians in the space continues to decrease.

Filled graduate medical education placements of physicians in geriatrics declined 23.3% between 2001 and 2018, according to Johnson’s study.

These findings come as the skilled nursing industry is beset by a severe staffing crisis, while leadership roles within facilities are quickly evolving due to a variety of factors — from new clinical demands to changing patient profiles and the introduction of new payment frameworks and technology platforms.

Furthermore, nursing home staffing patterns have been changed by the pandemic, as waivers granted under public health emergency (PHE) created new flexibilities. For example, certain non-physicians have been able to undertake tasks previously delegated exclusively to physicians.

On Monday, the Government Accountability Office (GAO) issued a report shining a light on some of these waivers, noting the difficulties in knowing how they have affected patient safety. The ability to glean data will be a key factor in whether some PHE flexibilities will be allowed even after the public health emergency ends.

Regardless of whether waivers end or are extended, nursing home clinical leaders such as Brickyard Healthcare Chief Compliance and Strategy Officer Wanda Prince have repeatedly emphasized the importance of creating more collaborative care teams that draw on expertise from a variety of clinical roles.