Case Management Depending More on Advanced Practice Nurses
Advanced practice nurses (APNs) are becoming case managers as part of a trend fueled by the growth of managed care.
- APNs helping with care coordination can contribute to improved quality of care and communication at discharge and reduce readmissions.
- Because of the COVID-19 pandemic, governors in some states signed emergency declarations to allow APNs to practice independently.
- APNs working with high-cost patients can help hospitals reduce costs and make the discharge process more efficient.
In some hospitals in the United States, advanced practice nurses (APNs) have become case managers, a trend that is boosted by managed care and broader healthcare trends.1
“Accountable care organizations are about saving money for hospitals and improving quality of care,” says Neeraj Puro, PhD, study co-author and assistant professor at Florida Atlantic University (FAU) College of Business.
While nine in 10 U.S. acute care hospitals provide case management services, only 12% of the hospitals use APNs to provide those services. The use of APNs still remains despite its growth due to managed care trends. Another factor is that hospitals with more severely ill patients are more likely to employ APN case managers, researchers found.1
The study’s results imply hospitals create opportunities for nurses to develop treatment plans that prevent high-need patients from overusing hospital resources — meaning APNs can benefit the hospital’s financial picture.
Adding APNs to a care coordination/case management program helps hospitals achieve improved quality of care, better communication at discharge, and fewer readmissions. “It’s important in improving the quality discharge of the patient,” Puro says.
In some states, APNs can prescribe medication, which also can lead to successful discharge outcomes, says Scott Feyereisen, PhD, the study’s lead author and assistant professor at FAU College of Business.
The use of APNs expanded during the COVID-19 pandemic as governors passed emergency declarations allowing APNs to practice independently to ease staffing shortages. “Some states say they can be independent; some states say not,” Feyereisen says.
But the pandemic’s effect on the overall healthcare workforce added weight to the argument that APNs should be independent in all states moving forward, Feyereisen says. The downside of more independent APNs is that fewer will be drawn to the case management role.
“We actually saw increased [APN] case managers in states where there were restrictions and where APN independence was less likely,” Feyereisen says.
For hospitals with high-cost patients due to illness severity, hiring APN case managers is a practical decision. “It’s all about the cost,” Puro says. “Case managers can make a good example of how hospitals reduce their costs. If you can cut costs by using APNs as case managers, then that’s one of the goals of the Affordable Care Act — to improve quality and cut costs.”
Physician acceptance is a roadblock to hiring APN case managers. As the study authors noted, some hospitals find physicians are not open to involving APNs in discharge planning and care transitions because it takes away some of the physicians’ discharge responsibilities. For instance, treatment plans designed by APN case managers might be met with physician resistance because they limit physicians’ decision-making power about patient treatment.
“Culture really matters in terms of how well they’re received,” Feyereisen says. “If APN case managers have a good working relationship with physicians, then things can go well; otherwise, things could be adversarial and result in turf wars.”
Any case management department that wants to incorporate APN case managers into its program should obtain physician buy-in. They should assess whether current staff is willing to accept this change, and they should plan how it would work.
“For example, maybe the physician could recommend a battery of tests for patients, and the APN says that only one can be done at a time from a cost standpoint,” Feyereisen says.
It is up to case management leadership and other departments to collaboratively decide the responsibilities of each person involved in discharge planning and care transition and to avoid potential areas of conflict and overlap. “Case managers can help improve efficiency and reduce duplication of services,” Puro says.
One way this helps is that APN case managers can carry out discharges without long waits for a physician’s signoff. This allows physicians to make their rounds and not worry about as many care transition details, Feyereisen says. This could save hours in bed turnovers, making discharges faster and more efficient — particularly when the hospital’s beds are full.
“APNs have more independence now than ever because of the pandemic,” Puro notes. “Let’s see what happens after COVID-19.”
The restrictions that were loosened could return when the pandemic ends. “It will be an interesting time in a year or two to see what happens,” Puro says.
“There’s a fair amount of research to show the benefits of increased usage and independence of APNs,” Feyereisen says. “Most APNs have doctorates with the education and experience, so why do some states allow them to do less than they’re trained for?”
From a researcher’s point of view, it is an interesting dynamic. “When APNs are case managers, the results are good,” Feyereisen says. “When APNs do their things, they tend to do well.”
- Feyereisen S, Puro N, Thomas C, et al. A new kind of gatekeeper: The increasing prevalence of advanced practice nurses as case managers in US hospitals. Health (London) 2021;25:596-612.
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