It takes a nurse . . . but what kind?

Nurses vary as much as patients

A recent study from the University of Pennsylvania in Philadelphia shows how supervision from advanced practice nurses (APNs) during an initial hospitalization and after discharge can help keep more elderly patients from being readmitted to treat chronic illness. Lead researcher Mary D. Naylor, PhD, FAAN, RN, says her control group of similarly aged and debilitated patients often needed more admissions because they did not receive such aggressive disease management.

In his commentary in the Journal of the American Medical Association about Naylor’s study, Peter A. Boling, MD, notes "medicine is entering an era of chronic disease management." Boling is associate professor of internal medicine at the division of general medicine at Virginia Commonwealth University’s Medical College of Virginia campus in Richmond and immediate past president of the American Academy of Home Care Physicians.

In the formal hospital setting, nurses track symptoms and tell their patients what to do to keep their conditions under control. And they do the same in a visit to a patient’s home.

"Nurses’ history had their roots in home care," Naylor says, noting nurses are "probably the predominant focus group."

But while many agree that a nurse truly belongs in this role, it still isn’t clear on how much training is needed to be the disease management supervisor.

Naylor’s study used five APNs; they have master’s degrees in gerontologic nursing. In the study, the team credited their clinical acumen and expertise working with physicians and other professional caregivers as benefiting the intervention efforts.

Some participants in the control group had access to home visits through the Visiting Nurse Association (VNA). In the study, these nurses are described as mostly generalists with bachelor’s degrees.

Naylor says the APN is the right choice for the study’s cases not only because of clinical experience, but because of "a fair level or risk" in terms of how much responsibility the nurse is taking when helping to make the decisions for the patient’s care. And in the dynamic of working with doctors, the APNs "create a collaborative relationship." They "negotiate a plan of care," and physicians and APNs have "a great deal of respect in each other’s judgment."

Not every elderly patient with heart failure may need this degree of care, however. "Traditional hospitalization and follow-up by VNA may be just fine," she says. "For some, it’s not adequate."

A big consideration is getting access to nursing at home, she says. In her study, six in 10 patients did not qualify for referral for a traditional home visit, although the study suggests they could get a lot of help from them. If patients can get around on their own, Naylor says, they are not eligible for a visiting nurse through Medicare, though they may still need a lot of medical attention.

Not all agree with Naylor when it comes to determining who is able to provide home services to chronically ill patients in order to keep them out of the hospital. "This is nothing new," says Pamela Sawyer, RN, MHA, vice president of business development and contracts for the Visiting Nurse Associations of America, the national organization that supports state VNA programs from its Boston headquarters. "VNA invented the profession 110 to 120 years ago."

Sawyer, who says she was "a bit taken aback" by the study, says the intervention sounds a lot like what VNA members do. "They described the patient we all see," she says, referring to the subjects in Naylor’s study. "These were the people we took care of. We called up on the weekends to ask are you OK, Mrs. Smith?’"

As far as financing, Sawyer says she sees problems in keeping the number of visits open to the discretion of the nurse, which is hard to manage if a hospital works on a budgeted dollar amount per patient, as VNA operates. Further, Sawyer says the VNA has even tougher financial restrictions imposed on it than the study implies because of changes in reimbursement rules that went into effect a year after the study began. Under the Health Care Financing Administration’s interim payment system, VNA must use 1993 reimbursement rates to fund 1999 programs.

It is financial restriction that forces VNA to cut back on experienced personnel, Sawyer says — but highly trained nurses do work for VNA, she says, as many have come from cardiac care units and the intensive care units, which have shown them how to provide sophisticated care at home.

And aside from the formal training, Sawyer notes VNA nurses know the communities where the patients live. These nurses, she says, know the community services in the area such as churches and support groups that can help when resources run short. "They know all that," Sawyer says, adding, "They work with all these things at their fingertips.

"I agree that home care keeps people out of the hospital." She says. "I question if you need an APN to do it."

"I don’t think the VNA could do this," says Boling. He notes whoever performs this sort of care has to know what’s going on with the patient while he or she is still in the hospital. If treatment changes need to be made, such as with medication, this caregiver could either do it personally or arrange for it to be done. VNA nurses usually do not have pharmacotherapy training and would not be appropriate.

Also, the caregiver needs to be working with doctors and pharmacists in the hospital, and most of the time, the VNAs don’t have those connections. But Boling notes: "I could be proved wrong by another study."

He says in order to pay for Naylor’s type of intervention, individual health systems will have to develop their own programs, analyzing their own costs and determining how much the program could save. Naylor, whose study was funded by grants from the National Institutes of Health, says savings such as those in her study will justify funding individual programs. The price of the advanced practitioner will cost more than the VNA nurse, she says. In the study, for example, the APN’s fee was 20% more than Medicare reimbursement for a VNA nurse.

Filling in the details on which nurse to use for each situation will be good for the health care industry, says Sharon L. Merritt, RN, MSN, EdD, associate professor at The University of Illinois-Chicago College of Nursing. More people will realize that the title "nurse" is used for a spectrum of caregivers. They range from two-year junior college graduates with a year of clinical experience to the advanced practice nurses who may hold a doctorate and trained beside medical residents in their third or fourth year of their clinical programs.

"What drives me absolutely crazy is the thought that a nurse is a nurse is a nurse," Merritt says. She adds that determining which nurse is used will eventually come down to the need of the patient. "The sicker the patient, the more advanced person you need."

"It depends on what’s being done," adds Ellen Daroszewski, RN, PhD, ACNP, nurse practitioner for the advanced heart failure clinic at Cedars-Sinai Medical Center in Los Angeles. The nurses who are prepared with an associate’s or a bachelor’s degree have some wonderful skills, she says, but evaluating a CHF patient’s needs and determining the proper comprehensive treatment is best done by someone at the advanced practice level.

Many of these experts note nurses will be able find their niche in treating CHF patients — whether it be in planning, delivering, or administrating the treatment. But since the advanced practice caregiver has some degree of authority to prescribe medication, these nurses (and pharmacists in some cases) will handle this aspect of care with physicians.