Use of nurse practitioners in primary care: Physician s perspective. Matthew McNabney, MD Johns Hopkins University 3 June 2016

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1 Use of nurse practitioners in primary care: Physician s perspective Matthew McNabney, MD Johns Hopkins University 3 June 2016

2 Objectives for today Describe the background and evolution of nurse practitionerphysician collaboration in the United States Understand the range of practice models which routinely incorporate nurse practitioners into the care of older adults Apply this knowledge in the development of models of care and practice redesign in Norway which incorporate nurse practitioners into primary care for older adults

3 Health care crisis for an Aging Society Institute of Medicine (2008, 2010) The current workforce is inadequate at all levels to provide the care needed Primary care is a particular concern Geriatricians and other primary care physicians insufficient Nurse practitioners (and other advance practice nurses, physician assistants) identified as important part of this solution

4 How about Nurse Practitioners? Originated in 1960 s, as alternative care provider with enhanced skills and autonomy (vs. nurses) but less time of formal training (vs. physicians) Slow initial growth; recently more rapid growth (in the US) 148,000 NPs in the US in 2011 (Source: AANP) or ~ 1 / 2000 people Scope of practice is quite variable by state (Gadbois 2015; Cassidy 2013) States with less restriction on NP practice (more autonomy), evidence suggests more primary care visits and fewer ER visits (Traczynski, 2013)

5 Terminology Nurse Practitioners Trained to be autonomous practitioners who work in collaboration with physicians Not physician extenders or mid-level providers Disregards the independent role of NP in the provision and coordination of care Better terms: clinicians, primary care providers, health care professionals Similar issue (in the US) with physician assistants (PA s)

6 Geriatrics and Nurse Practitioners Most (66%) of NPs are based in primary care practices (as compared to specialized practices) A merging of the training and preparation of adult nurse practitioners (ANP) and geriatric nurse practitioners (GNP) Began approximately 2010 Full embrace of team based care (AANP 2013)

7 APRN Regulatory Model Source: APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee (APRN and NCSBN, 2008). Consensus Model for APRN Regulation: Licensure, Accreditation, Certification & Education

8 APRN Regulatory Model Source: APRN Consensus Work Group and National Council of State Boards of Nursing APRN Advisory Committee (APRN and NCSBN, 2008). Consensus Model for APRN Regulation: Licensure,Accreditation, Certification & Education

9 Evidence for benefit of co-management Study evaluating two practice styles (MD alone vs. MD/NP comanagement) ACOVE 2 (Assessing Care of Vulnerable Adults) Common geriatric conditions (falls, urinary incontinence, dementia, depression) Co-management with NP had better outcomes overall and for each condition (except depression) (Reuben, J Am Geriatr Soc 2013)

10 More Evidence on Quality of Care Matched quality of primary care (vs. physicians) Naylor, 2010 Greater patient satisfaction (vs. physician) Horrocks, 2002 Better outcomes in nursing home care (ex: fewer avoidable hosp) Mukamel, 2015 However, majority of patients surveyed still prefer physician Dill, 2013

11 How do attitudes of physicians and NPs differ regarding scope of practice of NPs in primary care? Donelan (NEJM 2013) On certain things, there may be important differences Sites of care Roles Degree of autonomy

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17 The Interdisciplinary Team and NPs The role of interdisciplinary teams has been touted as essential to good primary care, especially for older adults NPs and other non-physician disciplines are more receptive (than physicians) to the notion of team care and training is team oriented Partnership for Health and Aging (JAGS 2014) Therefore, NPs have the potential to facilitate IDT more successfully (democratically) to ensure maximal output

18 Identified needs for growth of NP workforce Availability of geriatric-specific textbooks for NPs Number and abilities of geriatric NP instructors Clinical venues across the continuum of care (and available training hours) for adequate geriatric exposure With a combined adult and geriatric NP training program concern that training will retain balance and adequate instructor knowledge Well designed curricula which can be revised/updated easily Web-based training options (Auerhahn, J Am Acad Nurse Pract, 2010)

19 Summary Evidence supports that NPs in the US provide appropriate and high quality care for older adults in the primary care setting Restrictions on practice are decreasing with time (state - level) Norway can learn from our experience with regard to growth, expansion and training of NPs in developing an efficient network of providers to ensure quality of care and control costs

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