Greater Nurse Practitioner Presence Linked To Fewer Hospitalizations, Higher Hospice Use for Nursing Home Residents With Dementia

Nursing home residents with Alzheimer’s disease and related dementias (ADRD) appear to benefit from greater nurse practitioner (NP) involvement, with fewer hospitalizations and higher hospice use at end of life.

The number of differences in outcomes between extensive and minimal NP care was higher in states with a full scope of practice regulations than in states with restrictive regulations, according to a study published in JAMA Health Forum on Friday.

In other words, state regulations governing NP’s scope of practice have implications for end-of-life hospitalizations and hospice use for nursing home residents with ADRD – specifically regulations outlining whether NPs can practice without physician supervision and sign do-not-resuscitate (DNR) orders.


That’s because full DNR authority may encourage NPs to be more proactive about initiating goals of care discussions with patients and families, since the NP could sign the DNR order at the time of discussion.

In addition, authority of NPs to prescribe schedule II through V medications could help provide pain and symptom relief at end of life for these residents. While the Centers for Medicare & Medicaid Services (CMS) doesn’t allow NPs to certify patients as terminally ill to receive hospice services under Medicare, they can still refer patients and serve as attending physicians under hospice.

“In states with restricted practice authority, it may be more difficult for NPs to serve in that role and order treatments requested by the hospice agency … it may also be the case that these different regulations [on authority] may have an additive association,” researchers said.


The study included 334,618 residents with ADRD and fee-for-service Medicare claims. About 40.5% of these residents received minimal nurse practitioner care, 21.4% received moderate care and 38.0% received extensive care from an NP.

Adjusted hospitalization rates were lower for the third group receiving extensive care, while adjusted hospice rates were higher.

“This is consistent with prior studies showing that NPs are providing an increasing proportion of medical care in nursing homes,” researchers said.

There’s a growing ADRD population in nursing homes, combined with a shortage of geriatricians and other primary care physicians with the skills and capacity to see patients in a facility, researchers noted. As a result, NPs are likely filling an important role during end of life for many nursing home residents with ADRD.

Study authors Cyrus Kosar, PhD.; Vishnu Thapa, MPA, PhD; and Ulrike Muench, RN and PhD contributed to the report.

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