Effective Use of NPPs in Long Term Care

1. Effective Use of NPPs in Long Term Care William Hovland, MD, CMD Marc Nevin, MD, CMD Angel Rivera, BSHA

2. A passing phase or an evolving reality?

3. Pressures to include NPPs • Changing regulations to allow greater autonomy • Pressure from cooperate chains • Evolving models of practice: Evercare and signature care • Medicare managed care • Physician manpower issues

4. Locations of practice in long term care • SNF and NF closer working relationship • ALF: greater autonomy • House Calls

5. What's required • Collaboration : a process where a NPP works with one or more physicians to deliver health care services within the scope of practitioners expertise, provided for in jointly developed guidelines or other mechanisms as provided by State law • The collaborating physician does not need to be present with the NPP or make as independent evaluation of each patient

6. Supervision • Shared responsibility • Both the NPP and the MD in a team to ensure that patients are being cared for appropriately • Supervision evolves with the skill level of both the NPP and the MD

7. Collaborative practice will benefit many, but not necessarily all long term care physician practices

8. Non Physician Provider -NPP • Nurse Practitioner • Board of Nursing • Licenses • Registered Nurse • Nurse Practitioner • Prescriptive Authority • Physician Assistant • Board of Medicine • License • Physician Assistant

9. Why Collaborate • Expands the overall expertise of the practice • Collaboration between NPPs and Physicians shown to improve resident out come

10. State Regulations • NPP scope of practice is regulated at the state level and varies widely • NPPs and Physicians should know their state regulates prior to constructing a collaborative agreement

11. NP- Scope of Practice • NP must practice as part of care team • Appropriate collaboration and consultation • Maintain a written or electronic practice agreement • Must disclose that he or she is a Nurse Practitioner • Can prescribe Schedule II through IV controlled substances

12. PA- Scope of Practice • Similar to NP • Must see and evaluate any pt presenting for the same complaint twice in a single episode of care and having failed to improve significantly. • Must wear identification when seeing patients that clearly indicates that he or she is a PA. • Schedule II- IV

13. NPPs Cannot… • Admissions in SNF

14. NPPs Can…. • ALF • NF • Death Certificates • DNRs • Call • Schedule II – IV

15. Liability • “The law also provides that service on a patient care team by a member of the team does not, by the existence of such alone, establish or create liability for actions or inactions of other team members”

16. Physician Liability • Physician NOT automatically liable • Patient –Physician Relationship • The “Master- Servant” relationship • Four Factor Test

17. Virginia Law- Four Factor Test • Selection and engagement of the ‘servant’ • Payment of compensation • Power of dismissal • Power of control

18. Risk Management • Confirm licensure and professional qualification • Become familiar with Virginia Laws and regulations • Mutually agree upon scope of practice • Communication!!!! • Continuous Evaluation

19. Compensation • NPPs reimbursed 85% of Medicare allowable • Can bill most insurance directly • Check with various carriers

20. Compensation Models • Hourly • Salary • Productivity • Full • Training • Starting • Experienced • Expert

21. Collaboration in Practice • Foster best patient outcomes • Skills & Competencies • Interactive Process • Shared responsibility of Care