CLINICAL PRACTICE IN LONG-TERM CARE
Section Editor: Daniel Swagerty, MD, MPH, CMD
Opportunities for Advance Practice
Nurses in the Nursing Facility
Mary Pat Rapp, MSN, RN
Advance practice nurses (APNs) have emerged as valu-able members of the nursing facility interdisciplinary team. They function in a variety of roles, including clinical care, administration, nursing consultation, and education. Positive outcomes in key indicators of care and reduction in costs to the healthcare systems have been attributed to their practice. Barriers to imple-mentation of the role include regulatory issues, facility resistance, and difficulty adapting to the environ-ment. Facilitation of the role is enhanced by collegial relationships and role negotiation. There is strength in
the APN–physician collaborative model. The APN is likely to concentrate on prevention, restoration, main-tenance, and palliative care, allowing the physician to concentrate on complex medical problems. There is a need for APN practices to identify APN-sensitive out-comes, collect and analyze data, and disseminate findings.(J Am Med Dir Assoc 2003; 4: 337–343)
Keywords: Nurse practitioner; clinical nurse specialist; advance practice nurse; nursing home
Nurse practitioners (NPs) have teamed up with physicians to enhance the nursing and medical care available to institu-tionalized older adults. Documented positive outcomes and favorable legislation have facilitated the increased presence of advance practice nurses (APNs) in the nursing facility. The purpose of this article is to offer a historical perspective of APN practice in nursing facilities and to describe a variety of roles and practice models APNs have developed for a nursing facility practice. Outcomes associated with the various models are described. Educational preparation and key issues regard-ing state and federal regulations regardregard-ing APN practice are discussed. Finally, suggestions for implementing and manag-ing a successful, satisfymanag-ing nursmanag-ing facility practice are discussed.
The term nursing facility is used throughout this article and is inclusive of other commonly used terms, eg, nursing home, long-term care facility, skilled nursing facility, or nursing home care unit. Nursing facilities can be free-standing com-munity-based, or separate units in hospitals. They receive payment for services rendered from Medicare Part A, Medic-aid, Veterans Affairs, private insurance plans, and out-of-pocket from individuals. Services are interdisciplinary and
include assessment and coordination of care by registered nurses (RNs). Licensed vocational/practical nurses (LVNs/ LPNs) follow the plan of care established by the team. Most of the direct care is rendered by nursing assistants. The goals of care include appropriate management of acute conditions, restoration and maintenance of function, as well as comfort in dying.
HISTORICAL PERSPECTIVE
Geriatric nurse practitioners (GNPs) were first introduced to nursing facilities in the 1970s to improve access to medical services and to augment the role of the attending physician. The W. K. Kellogg Foundation through the Mountain States Health Corporation provided resources in which RNs were recruited from nursing facilities, then educated and trained in a continuing education model. Over a 10-year period from 1976 to 1986, 120 GNPs were trained and placed in facilities. They received approximately 4 months of didactic training followed by 8 months of clinical training in the practice site. Nearly all received their GNP education through university schools of nursing in western states, ie, Arizona, Colorado, Washington, and California. On finishing the program, they received a certificate of completion and were eligible to sit for the GNP examination offered by the American Nurses Cre-dentialing Center (ANCC).1
Local physicians were recruited to act as educational pre-ceptors, many of whom became collaborating physicians in practice. After graduation, the GNPs returned to the spon-soring facilities that had agreed to employ them in the role for at least 18 months. As facility employees, the GNPs provided University of Texas Health Science Center–Houston and Geriatric Associates of
America, Houston, Texas.
Address correspondence to Mary Pat Rapp, MSN, RN, University of Texas Health Science Center, Houston, TX 77030. E-mail: Mary.p.rapp@uth.tmc.edu
Copyright ©2003 American Medical Directors Association DOI: 10.1097/01.JAM.0000095253.60570.43
primary care services and enhanced nursing services by par-ticipating in quality improvement, infection control, staff education, and research. Positive outcomes associated with this model included a reduction in hospitalizations, improved management of chronic care, and greater attention to reha-bilitation and restorative services.2–4
In this day of exceedingly high turnover rates of nursing facility employees, it is worthwhile to take a look at the career paths of the first GNPs. Ten years after the program first began, a survey revealed the median length of time in thefirst position as a GNP was 4.5 years. Even when the GNPs left their initial position, most remained employed in a nursing facility in the advanced practice role. A remarkable 90% were still working in a nursing facility up to 8 years after training. Retention was most closely associated with prior experience working in the setting.5
A few certificate-trained GNPs remain in practice, but the continuing education model no longer exists. A num-ber of factors influenced the demise of the model. Since 1995, initial application for participation in Medicare has required APNs to have master’s degrees and national board certification. The ANCC now requires a master’s degree as preparation to sit for the GNP examination. Additionally, most states now require a master’s degree for current entry level into advance practice. Although GNPs continue to work in nursing facilities, the demand exceeds the supply. Adult and family NPs have joined the growing cadre of APNs caring for frail older adults.
Recognizing the need for systems management, facilities also began to use the services of clinical nurse specialists. Geriatric clinical nurse specialists (CNSs) have master’s de-grees and have similar knowledge to GNPs, but clinical train-ing focuses on populations or systems rather than individuals. For example, the CNS might plan and implement a fall management program for a healthcare system, whereas the NP would evaluate and manage falls in the individual resi-dent. Most CNSs provide consultation to nursing thus will practice independently; however, because of individual state practice acts, some CNS practices could be indistinguishable from NPs.
In the 1980s, fee-for-service medical groups began using NPs to provide primary care in nursing facilities. The primary role of the NP in fee-for-service was described as clinical for episodic and chronic care.6–8 Cost-effectiveness and
im-proved quality was attributed to reduced emergency depart-ment transfers, fewer hospitalizations, and improvedepart-ment in functional status.9,10 Academic teaching centers described
similar benefits using NPs to complement or substitute for physician services.11 Health maintenance organizations
(HMOs) began using NPs to reduce inpatient costs, and to improve coordination and quality of care.12,13
Consistent positive benefits attributed to the use of APNs for primary care services in the nursing facility provided the incentive for federal regulatory changes that increased resi-dent access to these new team members. The 1987 Omnibus Budget Reconciliation Act (OBRA ’87) allowed APNs to substitute for some physician visits with reimbursement from Medicare. Relaxation of the number of covered visits per
month has improved access to care in this traditionally un-derserved population. The 1997 Balanced Budget Act allowed APNs to bill Medicare independently for their services and expanded sites of service. Inspired by positive health out-comes, satisfaction in practice, and cost benefits associated with a nursing facility practice, a number of practice models has evolved.
CURRENT MODELS AND ASSOCIATED OUTCOMES
To identify practice models, a review of the literature from 1970 forward was performed on 2 advance practice roles, ie, NPs and CNSs, and outcomes in the nursing facility. A Boolean search of Medline and CINAHL was conducted using the terms nurse practitioner, clinical nurse specialist, and nursing home. Inclusion criteria placed a preference on qualitative research or quantitative studies in which the out-come was attributed to the APN role. Of the 218 titles located, 33 met inclusion criteria.
Five practice models for APNs were found and included fee-for-service, faculty practice, managed care, nursing con-sultant, and nursing facility employee. With the exception of nursing consultant, the primary function was clinical. Other roles included educator, researcher, administrator, and nurs-ing service consultant. Each model was reviewed for the description of functions performed, associated outcomes, and unanswered questions or challenges.
Fee-for-Service
In a fee-for-service model, the APN provides clinical eval-uation and management services in collaboration with the attending physician. The literature reflects that most APNs are employed by the physician’s practice or clinic, self-em-ployed, or employed by an APN group practice. Physicians cannot bill for services they do not provide; therefore, if self-employed, the APN will need to arrange for support services such as billing. Functions described include obtaining a health history, performing physical examinations, and de-veloping treatment plans for acute and chronic illness.6,7,14
Kane et al. reported statistically significant improvements in functional status and clinical management of selected chronic diseases when APNs were allowed to make unlimited medi-cally necessary visits.8Others have reported improved
prac-tice efficiency,6 more comprehensive documentation,14
en-hanced problem identification, improved resident outcomes,7
and reduced costs to Medicare and Medicaid.7,8
Generalization of study results in fee-for-service has been compromised by small sample sizes, inconsistency of reporting statistical significance, and the inability to separate the im-pact of the APN from the imim-pact of the physician–APN team. Regulatory changes have allowed APN substitution for physician services and permitted an increase in the frequency of provider visits, further compromising comparisons over time. Unanswered questions remain, including the optimal caseload census, the average number of encounters daily, productivity analysis, resident and facility satisfaction, and statistically significant clinical outcomes specific to APN intervention.
Faculty Practice
Academicians have recognized the need to offer geriatric long-term care experiences to medical students, medical res-idents, APNs, physician assistants, and other members of the interdisciplinary team. In 2 faculty practice reports, the role of the APN was clinical with an adjunct educational or admin-istrative role.11,15 Compared with usual care, an academic
model for nursing facility care, which included an APN and a geriatrician, demonstrated statistically significant improve-ments in functional status, discharge rates, transfers to acute care, staff morale, and resident satisfaction.11It was not
pos-sible to attribute positive outcomes solely to the presence of the APN and a cost-effectiveness analysis was missing.
Managed Care
Managed care organizations have used APNs extensively to provide primary care services to nursing facility residents in collaboration with physicians. The role of the APN in man-aged care is primarily clinical and includes prevention, chronic and episodic acute care, and coordination of services. Most APNs triage telephone calls from facilities during the day16–18and some share evening or night call.16,19
Nonclini-cal services often include staff education and quality improvement.17
Statistically significant favorable results have been reported in the managed care model, including reduction in emergency department transfers, hospitalizations, skilled nursing facility days,19 and timely response to acute problems.16 Economic
benefits of the HMO model have been attributed to the decreased utilization of hospitalization and reduction in emer-gency department transfers.20,21
One Medicare HMO exclusively serving nursing facility residents reported APNs spend 60% of their working day on resident care activities. They reported seeing an average of 8 residents per day with a caseload census of 84.22The number
of encounters and caseload appears low compared with fee-for-service; however, responsibilities for care management most likely explains the difference, but further clarity is needed. In a 2002 survey of APNs, the average number of visits per day in a geriatric practice was 13.22,29
Consultation
Consultation roles have included formal education, men-toring at the bedside, and outcomes monimen-toring. As quality improvement consultants to nursing, APNs have been effec-tive in improving the overall quality of care,23–25changing
behaviors to improve performance on single quality indica-tors,26,27 and demonstrate superior observational skills for
recognizing an acute change in condition.28Consultation by
a CNS with education or inservice as a single intervention to improve the process of care delivery and subsequent outcomes has not been as effective as presence in the facility with mentoring plus education.23,25Intensity and duration of
ed-ucation and mentoring have a positive effect on clinical outcomes, including restraint reduction and continence pro-motion.23,25,26Analysis of cost-effectiveness of APN
consul-tation for continence programs and wound care demonstrated cost savings for both initiatives.25
Collaboration with the medical director for education and quality improvement would be desirable; however, it has not been reported in the literature. Perhaps this is because quality improvement and education regarding nursing processes
re-flect the independent role of the clinical nurse specialist. Challenges to the consultation model include lack of in-line authority, staff resistance to change, and ineffective imple-mentation of process changes in the facility.
Facility Employee
The APN as facility employee represents a hybrid of nurs-ing consultation and fee-for-service. When the APN is hired by the facility, there could be a greater opportunity to inte-grate many roles, including clinical, administration, research, and educator. The Mountain States Project reported success-ful resident clinical and functional outcomes in facilities that directly employed the GNP.2 All of the data regarding the
APN as facility employee emerged from the Mountain States Project. There are no current studies or reports describing the evolution of this model, and the number of APNs who are employed by facilities is unknown. Also unknown are the outcomes associated with a CNS as the director of nurses. Their unique training in systems management and nursing makes them excellent candidates for an administrative role.
APN PRACTICE ENVIRONMENT ISSUES
Regulatory Environment
A variety of regulatory bodies influence the practice of an APN. Individual healthcare organizations or facilities can credential and approve clinical privileges. Individual states govern the degree of autonomy when the APN manages medical aspects of care and prescribes medicines and thera-pies. In some states, APN practice is governed by a state board of nursing; in others, governance occurs in conjunction with the board of medicine.29The educational preparation and the
practice site dictate the scope of practice. At the federal level, participation in Medicare adds another layer of rules and requirements for both the facility and the APN.
Regulations both enable and pose barriers to APN practice. Federal regulations for nursing facilities and state practice acts permit APNs to participate in managing the medical care of the residents. Corresponding Medicare rules allow for reim-bursement of services rendered. Occasionally, the rules and regulations between agencies are conflicting. For instance, APNs can perform and bill for an initial admission compre-hensive assessment in a hospital or ambulatory clinic, but not a skilled nursing facility. Furthermore, individual states have the option to allow APNs to perform the initial comprehen-sive service for non-Medicare Part A nursing facility admissions.
In a few states, APNs practice independently of physicians; however, when the APN establishes a relationship with an individual covered by Medicare, they will need a collaborat-ing physician. For most APNs, collaboration is a key compo-nent of practice regardless of setting or payor, and is discussed by Resnick and Bonner elsewhere in this issue of the journal.30
Reimbursement Issues
Medicare will reimburse APNs for services at 85% of the physician’s allowable fee. As of January 2003, any APN ap-plying for an initial Medicare number must meet the practice requirements of the state, have national certification, and possess a master’s degree. The states determine which services APNs can legally perform. The service must be one that would be a covered service for physicians, and finally, the APN must collaborate with a physician in performing the services.31
A frequently asked question is whether APNs can bill using the incident to rule in the nursing facility. Guidelines for the incident to rule stipulate that services are provided with the physician onsite and the APN provides care in follow up of the established plan. In other words, the care is rendered
“incident to”the physician’s plan of care. Incident to is not applicable in the nursing facility setting unless the residents are being seen in an established office in the facility and the physician is physically in the office suite while the incident to services are provided.32
Physicians can delegate medically necessary visits to APNs who are employees of the facility.33 Hiring an APN as a
clinical house officer is potentially afinancially viable option that can have significant positive functional and clinical benefits for the residents. Readers are referred to the white paper on medical necessity prepared by the American Medical Director’s Association (AMDA) as a useful guide to deter-mine covered services.32a
The most frequently used billing codes include those for comprehensive assessments, subsequent visits, and dis-charges. Comprehensive assessment codes are used for res-idents who are new admissions to the facility but not necessarily new to the physician’s practice. Comprehensive assessments are also done annually and with a significant change in condition. It is easier to think of the codes in terms of the function performed as opposed to new or established residents (Table 1).34
Credentialing and Privileges
Many employing agencies, HMOs, insurance plans, and the Joint Commission for Accreditation of Health Care
Organi-zations (JCAHO) mandate credentialing of APNs. Nursing facilities lag behind this trend, and few nursing facilities have formal procedures in place to credential or grant privileges to anyone, including APNs or physicians. Federal nursing facil-ity rules for participation in Medicare and Medicaid do not require it. Credentialing establishes that the APN is qualified to perform designated clinical activities. At a minimum, cre-dentialing will establish that the APN meets qualifications for advanced nursing practice in the state. Employers can verify this information by checking with the state organization that governs APNs.
The employer or setting grants privileges to perform clini-cal activities and procedures.35 The APN would expect to
have privileges to perform evaluation and management ser-vices within their scope of practice. GNPs have education and training to care for the older adult across settings and along the wellness continuum. Although caring for older adults is within their scope of practice, the intensity and duration of geriatric-specific training for family and adult nurse practitio-ners will vary.
During the orientation period, APNs and collaborating physicians might want to discuss frequently occurring, prob-lematic, or high-risk problems encountered in the practice. This allows for a focused orientation and facilitates successful initiation of practice.
Physician Delegation of Tasks
Nursing facility rules for participation in Medicare and Medicaid allow APNs to substitute for some physician ser-vices (Table 2).36Physicians cannot delegate the role of the
attending physician to an APN. Additionally, the medical director must be a physician. Required visits after admission under Medicare Part A to a skilled nursing facility and under Medicaid to a nursing facility include visits every 30 days for the first 90 days and every 60 days thereafter. In a skilled nursing facility, the initial required visit must be performed by the physician, and further required visits can alternate with the APN. For a Medicaid nursing facility admission, at the discretion of the state, the physician can delegate all the required visits. This does not relieve the physician of the responsibility of being available when medically necessary.
Table 1. Establishing Levels of Service CPT Code34 Purpose of the Visit
99301 Annual history and physical exam, or initial comprehensive visit* with low complexity
99302 Creation of a new plan of care following a significant change in functional status, or initial comprehensive visit* with moderate complexity
99303 Initial comprehensive visit* of high complexity 99311 Stable chronic disease, or problem focused visit
99312 Follow up of problem oriented phone call. Development of a stable new problem. Stable but responding inadequately to treatment or development of a minor complication. Follow up of chronic disease of moderate complexity.
99313 Unstable new complication, unstable new problem. Follow up on return from hospitalization or emergency department. Follow up of chronic disease of high complexity.
99315 Discharge planning 30 minutes or less 99316 Discharge planning over 30 minutes
CPT!current procedural terminology
Required visits cannot be delegated to an APN who is an employee of the facility. As an employee of the facility, they can perform episodic care if the service is medically necessary. Residents can be seen by the APN before the physician’s initial visit and more frequently than required if the service is medically necessary. For care-planning purposes, the facility is required to perform a comprehensive assessment by day 14 and to develop an interdisciplinary plan of care by day 21. The comprehensive assessment includes the minimum data set (MDS) and resident assessment protocols (RAPs). The MDS screens for 18 functional problems and the RAP guides further assessment and care planning. Ideally, the APN and physician would coordinate the initial required visit, certifi -cations, and medically necessary visits with the facility assess-ment and subsequent care plan to maximize incorporation of the medical plan of care. Optimal care by the APN/physician team includes evaluation and management of both functional problems and illness.
Implementing and Managing a Successful Practice
Four of the 5 models presented in this article demonstrated positive outcomes from APNs working in collaboration with physicians to provide medical care to nursing facility resi-dents. The remaining consultation model suggested benefits to the nursing system when the APN worked closely and consistently with the facility staff to improve processes of nursing care. Regardless of the model, there are unanswered questions regarding the optimal use of the APNs’time, effect on staff outcomes, and appropriate compensation.
In a fee-for-service model, the APN must learn to balance quality with productivity. In addition, the APN will need to negotiate nonbillable services with the employer, or consider establishing a fee for educational or consultative services requested by the facility. Medicare might look suspiciously on an APN who regularly sees a large number of residents a day or fails to use a variety of billing codes. Conversely, an
employer might feel the need to adjust the salary downward if the APN is not making sufficient visits to cover the salary and practice overhead costs. The APN might want to consider evaluating productivity by using a formula to calculate a percentage of productive time. Such a formula helps the APN to see trends in activity and to identify possible system prob-lems interfering with the work schedule.37
Coordination of care takes precedence over quantity of residents seen in managed care. Managed care models have demonstrated decreased utilization of acute care services, thus have saving costs for the organization. The challenge to the APN is ensuring necessary services while containing costs. A facility could have the nursing staff and skill level to care for an acutely ill resident, but the family or the resident could ask for emergency department transfer or hospitalization. The APN might need to provide some nail care services in lieu of visits to a podiatrist. The advantage of working in managed care appears to be the amount of time the APN devotes to caring for the resident, talking with families, and working with the staff.22
The APN as facility employee model appears to combine the benefits of fee-for-service, managed care, and consulta-tion. In addition, it could be an attractive option for nursing faculty who want to incorporate care of the frail elderly into the nursing school curriculum. Presumably, the APN would have a daily presence in the facility and would be able to evaluate and manage all residents, not just those on the managed care or physician caseload. Daily presence would enhance surveillance for early recognition of change in con-dition, which is crucial in preventing hospitalizations. As a facility employee, the APN can become more closely aligned with the medical director and participate in quality improve-ment initiatives. As a facility-based consultant, the APN would be able to provide ongoing mentoring and follow up of issues related to systems of care. Regardless of the model, the
Table 2. Physician Delegation of Tasks33 Initial required visit*
Initial
orders Certification Recertification Subsequentorders
SNFs
NP, CNS, PA employed by the
facility May notperform May notsign May notsign May not sign May sign NP, CNS not employed by the
facility May notperform May notsign May sign May sign May sign PA not employed by the
facility May notperform May notsign May notsign May not sign May sign NFs
NP, CNS, PA employed by the
facility May notperform May notsign May notsign N/A May sign NP, CNS, not employed by the
facility May notperform** May notsign May sign N/A May sign PA not employed by the
facility May notperform** May notsign May notsign N/A May sign
*Initial visit is defined asfirst regulatory visit and must be performed within 30 days of admission. **At the discretion of the states, the initial visit may be delegated to an NP, CNS, or PA
greatest challenge could be in implementing a successful practice.
Getting Started
Familiarity with the environment was an important factor in the success of thefirst GNPs. Respondents in a qualitative study exploring entry into a nursing facility practice identified an early need to make sense of the regulatory environment, understand the role and functions of various members of the interdisciplinary team, and figure out how to get the work done.38Table 3 lists professional resources that can link the
APN to others who are willing to share information and practice tips.
The APN will need to become acquainted with the lead-ership team consisting of the administrator, director of nurses (DON), and the medical director. The director of nurses will be a valuable resource regarding regulatory care issues and can help the APN understand the significance of the MDS for care planning, quality monitoring, and reimbursement. Most social workers are well-versed in residents’rights. An active and informed medical director will be valuable in interpreting regulatory guidelines and an important ally in role negotiation at the facility level.
The APN should negotiate with the administrator and DON the procedure and who to notify regarding nursing care-related issues. If a systemwide problem is identified, the APN might want to volunteer to participate in the quality improvement process. When voicing care concerns, the APN will most likely be eager to participate in the solution.
Nurse practitioners will benefit from a strong mentor and role model to maximize efficiency in making visits. Physicians and other APNs who have developed a systematic approach to their day will be the most helpful. In any collaborative practice, the work will need to be negotiated. Who is going to do the required visits? Will the physician and the APN alternate as allowed? Will the APN primarily attend to acute or episodic problems? What forms and orders can the APN sign?39In the case in which the collaborating physician is not
the attending physician, the APN and attending physician will need to negotiate physician notification. For instance, does the attending want to be notified before sending a
resident to the hospital, when an advance directive is signed, with changes in orders?
Generally, more communication early in the relationship will assist in developing trust. Daily telephone contact from new graduates to review all visits is not unreasonable. Essen-tial components of care management can be discussed over the phone, and the APN will gain knowledge and skills to use in future encounters. In addition, the physician will learn more about the unique nursing perspective and contribution the APN makes to the care management team.
FUTURE DIRECTIONS
There are opportunities to develop new models of practice in the nursing facility. In the process, APNs should be en-couraged to seek out assistance to collect data and monitor practice outcomes. The AMDA research network has com-mitted a work group to evaluate APN/physician collabora-tion. Other partnerships might include academic institutions or APN professional associations.
Many unanswered questions remain. Liability issues were not addressed in any of the models reviewed. Does the addi-tion of an APN to the care team improve resident, family, and staff satisfaction? If so, does this reduce liability, or is it related to some other factor? Does satisfaction differ among the var-ious models? If so, what contributes to the difference? Is there a difference in the various models and the facility quality-of-care indicators? What are the cost comparisons across the models?
There is sufficient outcome data to recommend the addi-tion of an APN to the facility roster of required employees.40
The diverse skills of APNs make them an ideal choice to facilitate quality improvement, improve quality of life for residents, and reduce healthcare costs.
SUMMARY
Nurse practitioners have become valuable members of the interdisciplinary care team for older adults residing in nursing facilities. Through creativity and innovation, several nursing facility models of APN practice have emerged. There are clear indications that positive clinical and functional outcomes have been associated with each model. Regulatory agencies have responded by enhancing resident access to APNs.
Establishing a nursing facility practice is both challenging and rewarding. Challenges can be met by understanding the rules and regulations, participating in the interdisciplinary care teams, andfinding a facility mentor. The ultimate reward is the opportunity to participate in improving services and outcomes for the residents.
REFERENCES
1. Kane RA, Kane RL, Arnold S, et al. Geriatric nurse practitioners as nursing home employees: Implementing the role. Gerontologist 1988;28: 469–477.
2. Kane RL, Garrard J, Skay CL, et al. Effects of a geriatric nurse practitio-ner on process and outcome of nursing home care. Am J Public Health 1989;79:1271–1277.
3. Buchanan JL, Bell RM, Arnold SB, et al. Assessing cost effects of nursing home based geriatric nurse practitioners. Health Care Financ Rev 1990; 11:67–68.
Table 3. Resources for Regulatory and Practice Information
Organization Website address
National Conference of Gerontological Nurse Practitioners
www.ncgnp.org
American College of
Nurse Practitioners http://www.nurse.org/acnp/ American Academy of
Nurse Practitioners http://www.aanp.org/default.asp National Association of
Clinical Nurse Specialists
http://www.nacns.org/
American Medical
4. Garrard J, Kane RL, Radosevich DM, et al. Impact of geriatric nurse practitioners on nursing-home residents’functional status, satisfaction, and discharge outcomes. Med Care 1990;28:271–283.
5. Radosevich DM, Kane RL, Garrard J, et al. Career paths of geriatric nurse practitioners employed in nursing homes. Public Health Rep 1990;105: 65–71.
6. Schultz PR, McGlone FB. Primary health care provided to the elderly by a nurse practitioner/physician team: Analysis of cost effectiveness. J Am Geriatr Assoc 1977;25:443–446.
7. Lowenthal G, Breitenbucher R. The geriatric nurse practitioner’s value in a nursing home. Geriatrics 1975;30:Nov.:87–91.
8. Kane RL, Garrard J, Buchanan JL, et al. Improving primary care in the nursing home. J Am Geriatr Assoc 1991;39:359–367.
9. Master RJ, Feltin M, Jainchill J, et al. A continuum of care for the inner city: assessment of its benefits for Boston’s elderly and high-risk popula-tions. N Engl J Med 1980;302:1434–1440.
10. Kane RL, Jorgensen LA, Teteberg B, et al. Is good nursing-home care feasible? JAMA 1976;235:516–519.
11. Wieland D, Rubenstein LZ, Ouslander JG, et al. Organizing an academic nursing home. JAMA 1986;255:2622–2627.
12. Kane RL, Huck S. The implementation of the EverCare demonstration project. J Am Geriatr Assoc 2000;48:218–223.
13. Polich CL, Bayard J, Jacobson RA, et al. A nurse-run business to improve health care for nursing home residents. Nurs Econ 1990;8:96–101. 14. Brody SJ, Cole L, Storey PB, et al. The geriatric nurse practitioner: A
new medical resource in the skilled nursing home. Journal of Chronic Disease 1976;29:537–543.
15. Panicucci C, Ingman S, Alyea B. The nurse practitioner–physician team in nursing home practice. Gerontology and Geriatrics in Education 1984/85;5:55–65.
16. Reuben DB, Schnelle JF, Buchanan JL, et al. Primary care of long-stay nursing home residents: approaches of three health maintenance orga-nizations. J Am Geriatr Assoc 1999;47:131–138.
17. Joseph A, Boult C. Managed primary care of nursing home residents. J Am Geriatr Assoc 1998;46:1152–1156.
18. Farley DO, Zellman G, Ouslander J, et al. Use of primary care teams by HMOs for care on long-stay nursing home residents. J Am Geriatr Assoc 1999;47:139–144.
19. Mezey M, Fulmer T, Burl J, et al. Geriatric nurse practitioners in long-term care: demonstration of effectiveness in managed care. J Am Geriatr Assoc 1998;46:506–510.
20. Burl JB, Bonner A, Rao M. Demonstration of the cost-effectiveness of a nurse practitioner/physician team in long-term care facilities. HMO Pract 1994;8:157–161.
21. von Sternberg T, Hepburn K, Cibuzar P, et al. Post-hospital sub-acute care: an example of a managed care model. J Am Geriatr Assoc 1997; 45:87–91.
22. Kane RL, Flood S, Keckhafer G, et al. How EverCare nurse practitioners spend their time. J Am Geriatr Assoc 2001;49:1530–1534.
23. Rantz MJ, Popejoy L, Petroski GF, et al. Randomized clinical trial of a quality improvement intervention in nursing homes. Gerontologist 2001; 41:525–538.
24. Ryden MB, Snyder M, Gross CR, et al. Value-added outcomes: the use of advanced practice nurses in long-term care facilities. Gerontologist 2000;40:654–662.
25. Stone RI, Reinhard SC, Bowers B, et al. Evaluation of the Wellspring Model for Improving Nursing Home Quality. Available at http://www. cmwt.org/programs/elders/stone_wellspringevaluation_550.pdf. Access-ed: October 12, 2003.
26. Evans LK, Strumpf NE, Allen-Taylor SL, et al. A clinical trial to reduce restraints in nursing homes. J Am Geriatr Assoc 1997;45:675–681. 27. Cadogan MPF, Osterweil D. Utilization of standardized procedures in
skilled nursing facilities: The California experience. Ann Long Term Care 1998; 6(4). Available at: http://www.mmhc.com/engine.pl? station!mmch&template!altcfull.html&id!56.
28. Jackson MM, Fierer J, Barrett-Connor E, et al. Intensive surveillance for infections in a three year study of nursing home patients. Am J Epidemiol 1992;135:685–696.
29. Pearson LJ. Annual update of how each state stands on legislative issues affecting advanced nursing practice. Nurse Pract 2003;28:35–58. 30. Resnick B, Bonner A. Collaboration: Foundation for a successful
prac-tice. J Am Med Dir Assoc 4:344–349.
31. CMS Nurse Practitioner Services and Clinical Nurse Specialist Services. Baltimore: Centers for Medicare & Medicaid Services; December 13, 2001. Transmittal 1734.
32. CMS Transmittal 1690. Washington, DC: Department of Health and Human Services; January 5, 2001.
32a.AMDA. White Paper on Determination and Documentation of Med-ical Necessity in Long Term Care Facilities. Baltimore, MD; 1999, revised 2001. Available at: http://www.amda.com/library/whitepapers/ mednecwhitepaper.htm. Accessed October 12, 2003.
33. CMS Physician Delegation of Tasks in Skilled Nursing Facilities (SNFs) and Nursing Facilities (NFs). Baltimore: Centers for Medicare & Med-icaid Services; April 10, 2003. Ref. S&C-03–18.
34. Harris TR, Gordy TR, Borman KR, et al., eds. Current Procedural Terminology, 20th ed. Chicago: American Medical Association; 1999. 35. Rustia JG, Bartek JK. Managed care credentialing of advanced practice
nurses. Nurse Pract 1997;22:90–92, 99–100, 102–103.
36. Pelovitz S. Physician delegation of tasks in skilled nursing facilities and nursing facilities. Centers for Medicare and Medicaid services [Ref. S&C-03–18]. Available at: http://www.cms.hhs.gov/medicaid/ltcsp/ SC0318.pdf. Accessed July 17, 2003.
37. Kearnes DR. A productivity tool to evaluate NP practice: monitoring clinical time spent in reimbursable, patient-related activities. Nurse Pract 1992;17:50–52, 55.
38. Bonnel W, Belt J, Hill D, et al. Challenges and strategies for initiating a nursing facility practice. J Am Acad Nurse Pract 2000;12:353–359. 39. Rapp MP. From the trenches. The NCGNP Newsletter. 1999;63:4, 8. 40. CMS Report to Congress; Appropriateness of Minimum Nurse Staffing
Ratios in Nursing Homes. Baltimore: Centers for Medicare & Medicaid Services, Summer 2001.
