Effective Use of NPPs in Long Term Care
William Hovland, MD, CMDMarc Nevin, MD, CMD
Angel Rivera, BSHA
A passing phase or an evolving reality?
Changing regulations to allow greater autonomy
Pressure from cooperate chains Evolving models of practice: Evercare and
signature care Medicare managed care Physician manpower issues
Pressures to include NPPs
SNF and NF closer working relationship ALF: greater autonomy House Calls
Locations of practice in long term care
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
What's required
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
Supervision
Collaborative practice will benefit many, but not necessarily all long term care physician practices
Nurse Practitioner ◦ Board of Nursing
Licenses Registered Nurse Nurse Practitioner Prescriptive Authority
Physician Assistant◦ Board of Medicine
License Physician Assistant
Non Physician Provider -NPP
Expands the overall expertise of the practice
Collaboration between NPPs and Physicians shown to improve resident out come
Why Collaborate
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
State Regulations
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
NP- 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
PA- Scope of Practice
Admissions in SNF
NPPs Cannot…
ALF NF Death Certificates DNRs Call Schedule II – IV
NPPs Can….
“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”
Liability
Physician NOT automatically liable
Patient –Physician Relationship
The “Master- Servant” relationship
Four Factor Test
Physician Liability
Selection and engagement of the ‘servant’
Payment of compensation Power of dismissal Power of control
Virginia Law-Four Factor Test
Confirm licensure and professional qualification
Become familiar with Virginia Laws and regulations
Mutually agree upon scope of practice Communication!!!! Continuous Evaluation
Risk Management
◦ NPPs reimbursed 85% of Medicare allowable
◦ Can bill most insurance directly
◦ Check with various carriers
Compensation
Hourly Salary Productivity
◦ Full◦ Training◦ Starting◦ Experienced◦ Expert
Compensation Models
Foster best patient outcomes
Skills & Competencies Interactive Process Shared responsibility of
Care
Collaboration in Practice