Sunday, April 17, 2011

Palliative care Nurse Practitioner Models of Care – It’s all about money. Or is it?




Within the context of an aging population, a US health care system in financial flux, and the shortage of primary care providers, nurse practitioners (NPs) are more and more in the news as a possible solution to provide primary and specialized care.

Marilyn Bookbinder and colleagues recently published an interesting read in the JPSM looking at the sustainability of two Palliative care nurse practitioner models serving people living with serious or chronic illness.

They looked at two models of providing NP based specialized palliative care to see if either of the models could generate enough revenue over a 2-year period to be considered financially sustainable. The first model consisted of an NP and a social worker (SW) with advanced training in palliative care. This palliative care home care team (PCHT-NP-SW) was based out of Beth Israel Medical Center and targeted underserved elderly homebound folks with advanced illness. Their goal was to provide symptom control, advance care planning and manage other quality of life issues. NP visits were billed using Medicare reimbursement figures. SW visits were not billable through Medicare. This team followed 114 patients at home.

The second model consisted of a hospice NP who was integrated into an existing home hospice agency associated with Beth Israel. Working in the Bronx, NY area, the goal of this model was to enhance the visibility of hospice care in the area, provide in-services, education, ensure optimal medical care for hospice related issues. There was no direct billing in this model. The authors projected that if this program resulted in an increase of their hospice census by at least 75 patients per year (assuming an average LOS of 45 days), the program would be sustainable (i.e. cover the salary of the NP).

Here’s the bottom line:

  • The PCHT-NP-SW did not prove sustainable. The billable visits covered only 55% of the NP salary, despite having made 350 visits (140 initial visits) during the project period. The SW made 1,000 visits (yes, 1000!), none of which were billable through Medicare as SW discipline is not billable (Grrrr).
  • The hospice NP model achieved financial sustainability within the first year. It was projected that the NP’s work brought in 264 admissions per year with an average stay of 55 days. This increase in the hospice census generated revenue that was about 7.5 times the NP salary.
  • While the PCHT-NP-SW program was discontinued, the hospice program hired 4 new NPs.


I wish that programs such as the PCHT-NP-SW model were not solely continued or discontinued based exclusively on their sustainability. I wish that more programs that served the unmet needs of the chronically ill and/or elderly populations were booming and viable. I wish that there was as much emphasis on formal geriatric training as palliative training for those serving these populations. I wish it wasn’t so frequently such an uphill battle to do what’s right. Often it is. But not always. In the Bay Area, there are some hospices that are footing the bill to provide palliative care NPs in hospitals and community nursing homes just because it’s the right thing to do. Will this provide more revenue for the hospice? Maybe. But they do it because it’s the right thing to do.

What do you think? How are NPs valuable in your setting? What innovative programs are you aware of in your community or health care setting? Are they “sustainable”?

6 comments:

Queen Bee said...

I read this study and have many of the same thoughts you have stated here. I am a GNP with a background in hospice and would dearly love to find a way to utilize my skills in the care of the chronically ill in a setting other than the SNF! Hospice/palliative care are the perfect setting for NPs and it really is a shame that reimbursement issues prevent full utilization of NPs in this role. Unfortunately there is no way (outside of hospice) to get paid for money that gets SAVED by keeping the chronically ill elderly out of the hospital and improving their quality of life.
D. Onken, DNP, GNP-BC

NYLegalNurse said...

The second NP role sounds more like the role of an outreach/educator. This would be an ideal role for the right NP. One of the biggest frustrations for Hospice professionals is the lack of time with the patient.

Providing an understanding to the community, developing professional relationships and educating the community on the use of hospice and palliative care, I feel will pay for the NP's salary by increasing the amount of time patients are on hospice.

The organization will be able to provide more of what that patient and that patient's family needs.

A win win situation.

We might want to take this a step further and add a program like Project Grace in Tampa. Project Grace is affiliated with Suncoast hospice and provides a clearinghouse of information on Advance Directives as well as training to educate the community on becoming Advance Care Planning Facilitators.

Perhaps implementing a program like this in New York would be a way to increase our utilization of Palliative Care as well as the use of meaningful Advance Directives.

So often I hear friends and loved ones say. I completed a living will with my attorney and when I ask if they have spoken with a health care professional, they miss the connection and the need.

I see this NP's role as a community educator. A community educator for both the community at large and for other health care professionals.

stanley said...

I'm surprised that Beth Israel didn't make the leap and fund the PCNP/SW practice with part of the 7.5x the hospice NP's salary that the hospice NP's work generated. Perhaps some other organization can take this one step further and use revenue-producing parts of their service to fund areas of group practice which are equally valuable, but may not produce revenue under the current rules.

Anonymous said...

The development of coordinated models of care will require much greater innovation. As care moves funding that is not fee-for-service, there is a potential to develop models that will be based on rational use of services directed to patient care needs/and quality. The tendency of current models to cost shift and avoid "risky" high cost patients will need to be curved or curtailed.

Cyndi, RN, OCN, PCRN said...

It seems that the outreach position could be a nurse educator & doesn't need to be an NP. But with the increase of funds from this position, it could help fund NP's (& SW's at least on a limited basis) at the bedside where their skills can be greatly utilized...

Christopher Langston said...

Great post - but I would resist making the assumption that "profitable in fee-for-service" = "sustainable." Outside of health care, "sustainable" usually means something that makes more efficient use of resources, perhaps even at higher cost so as to permit some long-term survival. In an ACO or capitated environment your home care paliative care program is not sustainable, but profitable.

Even in a fee-for-service environment I don't think sustainable should be used as a synonym for profitable. First, it is pretty clear that the financial environment is changing. Second, waste is still waste (not a sustainable practice). And third, there are mechanisms such as public fundraising, grants, volunteer work, etc., which can make an unprofitable enterprise sustainable.

Good luck on your efforts.