- Email: [email protected]
Research brief: National Provider Identifier database: Can it be a useful workforce tool?
Geriatric Nursing 34 (2013) 162e165
Contents lists available at SciVerse ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
Research brief: National Provider Identifier database: Can it be a useful workforce tool? Debra Bakerjian, PhD, RN, FNP, Kathy Speegle-Clark, MS(c), BSN, RN, Eduard Poltaviskiy, BS, Chin-Shang Li, PhD
1. Background The U.S. Census Bureau predicts the number of older adults will more than double in the next 20 years. Our ability to meet the health care demands of this population with more chronic illnesses is dependent upon adequate geriatric trained providers, yet accurately identifying the geriatric workforce is challenging. Past methods have relied upon surveys of professional organization and labor force statistics. Validity of these workforce estimates has been questioned because of individual inconsistencies in identifying a geriatric specialty, inherent problems of self-reported data, and lack of data from groups such as self-employed persons or those not certified but working in the industry.1 As many advanced practice nurses are aware, each of us who provide Medicare or Medicaid services have been required to enter information into a national registry system in order to be a provider for Medicare or Medicaid patients. This registry, the National Provider Identifier (NPI) database2 is a searchable, online, HIPAA compliant public registry of all provider organizations and clinicians who provide Medicare and Medicaid services, available since September 2007. The registry provides a 10 digit unique identification number that replaces provider social security numbers that were previously used as identifiers. The main purpose of the NPI database is to be able to identify all clinical and institutional providers and link through this unique identification number for purposes of payment and provides a taxonomy to identify provider specialty. The NPI registry includes data for almost 3.5 million providers of which 2.6 million are clinicians. Historically, we have used data from a variety of sources to determine the geriatric workforce. Typically, surveys such as the National Sample Survey of Registered Nurse that is conducted every four years by Health Resources and Services Administration (HRSA) along with professional organization surveys, have been used to 0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.02.007
provide information about the nurse workforce. Unfortunately, these have not been very effective in identifying the geriatric advanced practice nurse (APN) workforce that works in nursing homes.3 2. Purpose of study We conducted a study of the NPI database to analyze whether the NPI database could do a better job of identifying the APN workforce than traditional survey methods. We hypothesized the database may be a more accurate source of identifying geriatric workforce data when compared with professional organizations that rely upon sample surveys and Bureau of Labor Statistics that uses multiple data sources for estimates. Hypothesis of increased accuracy comes from regulatory requirements to use the NPI identifier for payment, provides specific field such as licensure and certification, that there are prescribed taxonomies that each clinician or provider organization must identify with, and that the downloadable file contains only active data. 3. Methods We developed a unique algorithm for the NPI database in order to identify geriatric clinicians and applied this series of screens to the database. This brief report highlights just the information on individual APNs that provide care to older adults. In this process we first targeted APNs who self-identified as geriatric trained, added those APNs who chose a geriatric taxonomy, and then added those who identified with a geriatric organizational provider. Once we had that list, we deleted all duplicates. We conducted a cross sectional analysis of the data to hone in on the number of APNs providing geriatric care. 4. Results Initial results were reported at the 2012 American Public Health Association conference in San Francisco. Table 1 shows just the findings for APNs providing care to older adults. We identified 2522 unique APNs who are clearly providing care to older adults, most (n ¼ 2065) were gerontological nurse practitioners (GNPs) with the others as either adult or primary care NPs. Only 7 APNs identified themselves as being in long-term care. Unfortunately, it was not as good a source of identifying geriatric APN workforce as we predicted; however, we were able to identify important issues related to the use of the NPI database that may prove useful for the future.
GAPNA Section / Geriatric Nursing 34 (2013) 162e165 Table 1 APNs who report geriatric affiliation in the NPI database. Health care provider
Health care provider taxonomy code_1
Number
Identified as geriatric workforce
Adult NP GNP Primary care NP Gero CNS Long term care Total
363LA2200X 363LG0600X 363LP2300X 364SG0600X 364SL0600X
14,126 2065 1229 128 7
312 2065 10 128 7 2522
5. Discussion There were a variety of challenges in working with the database that precluded specific APNs providing geriatric care. One major problem was the fact that the field that included “certifications”, a key area that individuals could use to self-identify their geriatric affiliation was free text. In other words, a gerontological nurse practitioner (GNP) could freely enter credentials into the field. We identified multiple ways in which GNPs identify themselves (Table 2). Some of these are due to differences in the certifying body requiring the APNs to report their certification differently (GNP-C, FNP-BC, etc.) and others were due to state licensure differences in how APNs signify their practice. A major factor was the use of periods, spaces, hyphens, capital letters and the order of the acronyms after the name. There were literally hundreds of variations in the different combinations of types of licensure, types of certification and the use of periods, spaces, and hyphens for the various APNs that made it challenging to organize the data. Table 2 Examples of differing ways of reporting credentials. GNP GNP-BC G.N.P. - B.C. GNP-C G.N.P.-C GNP - BC GNP - C MSN, GNP-C MSN, G.N.P. - C M.S.N., N.P. M.S.N., GNP-C M.S.N., RNP MSN, R.N.P.-C M.S.N., C.R.N.P. RNP
6. So what? The purpose of reporting this segment of this study in this journal is to highlight the confusion that gets created with the various ways in which APNs who care for older adults identify themselves. Within the profession, we should begin to examine how we identify ourselves and at least begin a dialog. Our study group will be making recommendations to the NPI database for changes that could significantly improve the ability to use the database for workforce analysis in the near future. 7. Policy implications Census Bureau estimates indicate at least a doubling of the older population in the next few decades. Specific, accurate data of the geriatric workforce will assist workforce planners, health care educators and policymakers to better meet the demand for care.
163
Having a systematic method for the use of “initials” to identify licensure and certification would be helpful to reduce confusion by researchers, other health care professionals and the public at large. References 1 Center for Health Workforce Studies, School of Public Health, University at Albany. The Impact of the Aging Population on the Health Workforce in the United States. March, 2006. HRSA Grant Number: U79HP00001. 2 Centers for Medicare & Medicaid Services website on National Plan and Provider Enumeration System. https://www.cms.gov/ NationalProvIdentStand/06a_DataDissemination.asp. Accessed 01.08.11. 3 Bakerjian D, Harrington C. Factors associated with the use of Advanced Practice Nurses/Physician Assistants in a fee-forservice nursing home practice: a comparison with primary care physicians. Res Gerontol Nurs. 2012;5(3):163e173.
Sewing an all-inclusive quilt from home and community based services for frail elders: A communityeacademic house call program partnership Jean Yudin, GNP-BC
The University of Pennsylvania Health System (UPHS), working together with the Philadelphia Corporation on Aging (PCA), has been operating the Elder-PAC program in Philadelphia for 15 years for Medicaid Waiver and Options clients. ElderPAC combines home and community based services through PCA with medical care in an integrated academic health system. The ElderPAC interdisciplinary team consists of a nurse practitioner and a physician from UPHS, a case manager from PCA, and a community nurse from HHA. The results of this partnership have been demonstrated in 2 five year evaluations between 1998-2000, showing a 40-50% reduction in Medicare costs, 20 additional months of survival in the community, compared to matched home and community based care controls, and a 4-fold decrease in nursing home months, resulting in 23% lower Medicaid costs than traditional Waiver. Interdisciplinary teams providing continuous, coordinated care to frail elders in the community can result in longer survival and lower costs, a dominant policy.
The cost of caring for frail elders with multiple chronic conditions and functional impairments weighs heavily on public programs, particularly for those frail elders who are both Medicare and Medicaid beneficiaries. Such dual eligible patients are among the frailest, least educated and most expensive of Medicare beneficiaries. A number of approaches have been tried to improve clinical outcomes and reduce costs in this difficult population. Common to the successful approaches is involvement of an interdisciplinary team, that has responsibility for the costs and care outcomes of a defined group of elders. Among such integrated long-term care programs, PACE (Programs of All Inclusive Care for Elders) is the accepted gold standard, providing integrated service delivery,
164
GAPNA Section / Geriatric Nursing 34 (2013) 162e165
patient-centered care focused at the patienteprovider level, supported by integrated funding.1 The Truman G Schnabel In-home primary care program is a nurse practitioner led house call program that has been in existence for 18 years. It is housed in the Division of Geriatrics, Department of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. This program was developed as an outgrowth of the ambulatory care practice. As patients were often unable to keep office appointments, these patients were seen ad hoc by providers who made visits around office their hours. Since being formalized in 1994, the house call program has grown to a practice of 200 patients, with home visits are limited to the geographic area within a 5-mile radius of the academic center. This program provides ongoing primary care in the home to frail, elderly, urban dwelling individuals. Primary medical problems include dementia, COPD, CHF, Parkinson’s disease, stroke, Diabetes and the many other comorbidities. The majority of patients enrolled in this program are over 80 years of age, female and are eligible for both Medicare and Medicaid. Referrals to the house call program come from ambulatory practices within the health system, emergency rooms, specialized units within the hospital, community agencies such as the Area Agency on Aging (AAA), home health agencies, community and senior centers, family members and patients. New patients are first evaluated by the APN who performs a complete examination, orders needed tests and, with the family, puts into place an initial plan of care. A physician visit is made within 2e4 weeks and patients are than seen every 6 weeks and acutely when needed. Joint visits are made to patients with complex, unstable physical and social needs. Over the course of a year, a patient is seen by the physician 2e4 times and has 6e9 nurse practitioner visits. The core medical team includes 2 nurse practitioners (1.5 FTE), 3 physicians (.3 FTE), one social worker (.5 FTE) and one service coordinator. Other core members include 2 caseworkers from the AAA and 3 nurses from the University of Pennsylvania Health System ’s home health agency, 2 nurses following all non-hospice patients and one hospice registered nurse (RN). Collaborations have been made with podiatrists and optometrists to make home visits and there is the capability for in-home lab draws, diagnostic studies including EKGs, CXRs, echocardiograms, and ultrasound studies. Reimbursement for APN visits comes from Medicare (both fee for service and managed care). Most, but not all, patients are so frail as to require the ongoing, complex, coordinated care from this full interagency team. For these patients, ElderPAC (Elder Partnership for All-inclusive Care) combines home and community-based services provided through the AAA with medical care from the integrated academic health system. Weekly team meetings with the core medical team and nursing staff and monthly meetings with the area on aging caseworkers as well as daily phone, email and texting provide the communication glue that holds the team together. The team members housed in the medical school use an electronic medical record that enables providers to have access to information when a patient is seen by another provider or is being evaluated in the emergency room. Lack of interoperability of EMRs with the other EPAC partners (including the health system’s own home health agency) remains a limitation. Over the course of the past decade, we’ve conducted 2 evaluations of our ElderPAC program to address the question if an interagency interdisciplinary team providing comprehensive, all inclusive care could (a) Increase the share of total survival spent in the community for frail elders, and (b) Reduce Medicaid nursing home costs by providing home- and community-based
care to frail elders. Using either a case control analysis or costs compared to home- and community-based care predicted Medicare costs, ElderPAC has shown a 50% reduction in Medicare costs over the past 10 years. Medicaid spending was reduced by 24%, driven by a 80% reduction in the share of time spent in nursing facilities among EPAC patients. ElderPAC consumers had a 40% increase in community survival, compared to traditional HCBS participants. At the end of the 5-year evaluation period, over 38% of EPAC consumers were still alive in the community, compared to 20% of traditional HCBS consumers. These outcomes are comparable to those of similar PACE programs.13 Table 1 has a list of comparable outcomes for EPAC and traditional waiver consumers. The range of savings compared to the predicted total Medicare costs was from 37 to 48%, depending upon the baseline used for projection. Table 1 Comparable outcomes for EPAC and traditional waiver programs.
Hospital Long-term nursing home Community survival/5-year survival Medicaid cost yr/5 yr HCBS/NH (PBPM) Est. mean HCC annual/5-yr total Medicare savings annual/5-yr total @ .48 @ .37
E-PAC 2 (2004e2009) (N ¼ 92/4360 member months)
Waiver/options controls (N ¼ 216/6910 membermonths)
3.8/100 mm 5.9% 38%/43% $20,640/$7.5 M $1448/$271 3.55 $41,962/ $15.3 M
7.2/100 mm 24.9% 20%/28% $27,084/9.8 M $1084/$1172 n/a n/a
$20,054/$7.22 M $15,458/$5.5 M
The Schnabel in-home program was recently selected to participate in CMS’ Independence at Home demonstration project as a member of the Mid-Atlantic consortium. Independence at Home is an effort to provide for multidisciplinary patienteprovider centered care, integrated across sites of health care, and over time, with a funding mechanism to reinforce such care, in the free for service Medicare world. References 1. Wieland D, Kinsoian B, Stallard E, et al. Does Medicaid pay more to a Program of All-Inclusive Care for the Elderly (PACE) than for fee-for-service long term care? J Gerontol A Biol Sci Med Sci. 2012. http://dx.doi.org/10.1093/Gerona/gls137. 2. Wieland D, Boland R, Baskins J, et al. Five year survival in a program of all-inclusive care for elderly compared with alternative institutional and home and community based care. J Gerontol A Biol Sci Med Sci. 2010. doi:10.1093/Gerona/glq040. 3. Meret-Hanke L. Effects of the program of all-inclusive care for the elderly on hospital use. Gerontologist. 2011. http://dx.doi. org/10.1093/geront/gnr040.
Interprofessional education and practice Debra Bakerjian, PhD, RN, FNP
We have all been hearing the importance of interprofessional education and practice over the last several years. The IOM Report,
GAPNA Section / Geriatric Nursing 34 (2013) 162e165
Future on Nursing1 and the World Health Organization, Framework for action on interprofessional education and collaborative practice2 are just two examples of recent reports highlighting the importance of focusing on improving our fragmented system of health care and inefficient use of our current workforce. Each of these important reports highlights key messages that focus on the importance of starting the discussion of collaboration and interdisciplinary teams early in the education process. Educators can be role models for how this can be done by collaborating with other disciplines in the classroom, bringing the interdisciplinary team together for case studies, and providing the environment for students to challenge the status quo. Additionally, competencies related to interprofessional education and practice3 and team science4 are readily available as resources. As Advanced Practice Nurses (APNs), we all should be examining our own practices based on the expert recommendations. In the classroom, that may mean integrating the interprofessional competencies into our course work as well as bring teams together to co-teach students and teaching students about team science. In practice, it means working together to develop better and more efficient models of care delivery that maximizes the use of the entire interprofessional team, discarding old belief systems that maintain rigid boundaries of who provide care
165
based historical turf, and being willing to change our own behaviors. Being familiar with the interprofessional literature and expert discussion on team science is an important start toward changing practice.
References 1 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010. http://www.iom.edu/Reports/2010/ The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Accessed 14.01.13. 2 World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice (WHO/HRH/ HPN/10.3). 2010. http://www.who.int/hrh/resources/framework_ action/en/. Accessed 14.01.13. 3 Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. 2011. http://www. aacn.nche.edu/education-resources/ipecreport.pdf. Accessed 14.01.13. 4 Josiah Macy Jr Foundation. Conference on Interprofessional Education. 2012. http://macyfoundation.org/docs/macy_pubs/ JMF_IPE_book_web.pdf. Accessed 14.01.13.
Contents lists available at SciVerse ScienceDirect
Geriatric Nursing journal homepage: www.gnjournal.com
GAPNA Section
Research brief: National Provider Identifier database: Can it be a useful workforce tool? Debra Bakerjian, PhD, RN, FNP, Kathy Speegle-Clark, MS(c), BSN, RN, Eduard Poltaviskiy, BS, Chin-Shang Li, PhD
1. Background The U.S. Census Bureau predicts the number of older adults will more than double in the next 20 years. Our ability to meet the health care demands of this population with more chronic illnesses is dependent upon adequate geriatric trained providers, yet accurately identifying the geriatric workforce is challenging. Past methods have relied upon surveys of professional organization and labor force statistics. Validity of these workforce estimates has been questioned because of individual inconsistencies in identifying a geriatric specialty, inherent problems of self-reported data, and lack of data from groups such as self-employed persons or those not certified but working in the industry.1 As many advanced practice nurses are aware, each of us who provide Medicare or Medicaid services have been required to enter information into a national registry system in order to be a provider for Medicare or Medicaid patients. This registry, the National Provider Identifier (NPI) database2 is a searchable, online, HIPAA compliant public registry of all provider organizations and clinicians who provide Medicare and Medicaid services, available since September 2007. The registry provides a 10 digit unique identification number that replaces provider social security numbers that were previously used as identifiers. The main purpose of the NPI database is to be able to identify all clinical and institutional providers and link through this unique identification number for purposes of payment and provides a taxonomy to identify provider specialty. The NPI registry includes data for almost 3.5 million providers of which 2.6 million are clinicians. Historically, we have used data from a variety of sources to determine the geriatric workforce. Typically, surveys such as the National Sample Survey of Registered Nurse that is conducted every four years by Health Resources and Services Administration (HRSA) along with professional organization surveys, have been used to 0197-4572/$ e see front matter Ó 2013 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.gerinurse.2013.02.007
provide information about the nurse workforce. Unfortunately, these have not been very effective in identifying the geriatric advanced practice nurse (APN) workforce that works in nursing homes.3 2. Purpose of study We conducted a study of the NPI database to analyze whether the NPI database could do a better job of identifying the APN workforce than traditional survey methods. We hypothesized the database may be a more accurate source of identifying geriatric workforce data when compared with professional organizations that rely upon sample surveys and Bureau of Labor Statistics that uses multiple data sources for estimates. Hypothesis of increased accuracy comes from regulatory requirements to use the NPI identifier for payment, provides specific field such as licensure and certification, that there are prescribed taxonomies that each clinician or provider organization must identify with, and that the downloadable file contains only active data. 3. Methods We developed a unique algorithm for the NPI database in order to identify geriatric clinicians and applied this series of screens to the database. This brief report highlights just the information on individual APNs that provide care to older adults. In this process we first targeted APNs who self-identified as geriatric trained, added those APNs who chose a geriatric taxonomy, and then added those who identified with a geriatric organizational provider. Once we had that list, we deleted all duplicates. We conducted a cross sectional analysis of the data to hone in on the number of APNs providing geriatric care. 4. Results Initial results were reported at the 2012 American Public Health Association conference in San Francisco. Table 1 shows just the findings for APNs providing care to older adults. We identified 2522 unique APNs who are clearly providing care to older adults, most (n ¼ 2065) were gerontological nurse practitioners (GNPs) with the others as either adult or primary care NPs. Only 7 APNs identified themselves as being in long-term care. Unfortunately, it was not as good a source of identifying geriatric APN workforce as we predicted; however, we were able to identify important issues related to the use of the NPI database that may prove useful for the future.
GAPNA Section / Geriatric Nursing 34 (2013) 162e165 Table 1 APNs who report geriatric affiliation in the NPI database. Health care provider
Health care provider taxonomy code_1
Number
Identified as geriatric workforce
Adult NP GNP Primary care NP Gero CNS Long term care Total
363LA2200X 363LG0600X 363LP2300X 364SG0600X 364SL0600X
14,126 2065 1229 128 7
312 2065 10 128 7 2522
5. Discussion There were a variety of challenges in working with the database that precluded specific APNs providing geriatric care. One major problem was the fact that the field that included “certifications”, a key area that individuals could use to self-identify their geriatric affiliation was free text. In other words, a gerontological nurse practitioner (GNP) could freely enter credentials into the field. We identified multiple ways in which GNPs identify themselves (Table 2). Some of these are due to differences in the certifying body requiring the APNs to report their certification differently (GNP-C, FNP-BC, etc.) and others were due to state licensure differences in how APNs signify their practice. A major factor was the use of periods, spaces, hyphens, capital letters and the order of the acronyms after the name. There were literally hundreds of variations in the different combinations of types of licensure, types of certification and the use of periods, spaces, and hyphens for the various APNs that made it challenging to organize the data. Table 2 Examples of differing ways of reporting credentials. GNP GNP-BC G.N.P. - B.C. GNP-C G.N.P.-C GNP - BC GNP - C MSN, GNP-C MSN, G.N.P. - C M.S.N., N.P. M.S.N., GNP-C M.S.N., RNP MSN, R.N.P.-C M.S.N., C.R.N.P. RNP
6. So what? The purpose of reporting this segment of this study in this journal is to highlight the confusion that gets created with the various ways in which APNs who care for older adults identify themselves. Within the profession, we should begin to examine how we identify ourselves and at least begin a dialog. Our study group will be making recommendations to the NPI database for changes that could significantly improve the ability to use the database for workforce analysis in the near future. 7. Policy implications Census Bureau estimates indicate at least a doubling of the older population in the next few decades. Specific, accurate data of the geriatric workforce will assist workforce planners, health care educators and policymakers to better meet the demand for care.
163
Having a systematic method for the use of “initials” to identify licensure and certification would be helpful to reduce confusion by researchers, other health care professionals and the public at large. References 1 Center for Health Workforce Studies, School of Public Health, University at Albany. The Impact of the Aging Population on the Health Workforce in the United States. March, 2006. HRSA Grant Number: U79HP00001. 2 Centers for Medicare & Medicaid Services website on National Plan and Provider Enumeration System. https://www.cms.gov/ NationalProvIdentStand/06a_DataDissemination.asp. Accessed 01.08.11. 3 Bakerjian D, Harrington C. Factors associated with the use of Advanced Practice Nurses/Physician Assistants in a fee-forservice nursing home practice: a comparison with primary care physicians. Res Gerontol Nurs. 2012;5(3):163e173.
Sewing an all-inclusive quilt from home and community based services for frail elders: A communityeacademic house call program partnership Jean Yudin, GNP-BC
The University of Pennsylvania Health System (UPHS), working together with the Philadelphia Corporation on Aging (PCA), has been operating the Elder-PAC program in Philadelphia for 15 years for Medicaid Waiver and Options clients. ElderPAC combines home and community based services through PCA with medical care in an integrated academic health system. The ElderPAC interdisciplinary team consists of a nurse practitioner and a physician from UPHS, a case manager from PCA, and a community nurse from HHA. The results of this partnership have been demonstrated in 2 five year evaluations between 1998-2000, showing a 40-50% reduction in Medicare costs, 20 additional months of survival in the community, compared to matched home and community based care controls, and a 4-fold decrease in nursing home months, resulting in 23% lower Medicaid costs than traditional Waiver. Interdisciplinary teams providing continuous, coordinated care to frail elders in the community can result in longer survival and lower costs, a dominant policy.
The cost of caring for frail elders with multiple chronic conditions and functional impairments weighs heavily on public programs, particularly for those frail elders who are both Medicare and Medicaid beneficiaries. Such dual eligible patients are among the frailest, least educated and most expensive of Medicare beneficiaries. A number of approaches have been tried to improve clinical outcomes and reduce costs in this difficult population. Common to the successful approaches is involvement of an interdisciplinary team, that has responsibility for the costs and care outcomes of a defined group of elders. Among such integrated long-term care programs, PACE (Programs of All Inclusive Care for Elders) is the accepted gold standard, providing integrated service delivery,
164
GAPNA Section / Geriatric Nursing 34 (2013) 162e165
patient-centered care focused at the patienteprovider level, supported by integrated funding.1 The Truman G Schnabel In-home primary care program is a nurse practitioner led house call program that has been in existence for 18 years. It is housed in the Division of Geriatrics, Department of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania. This program was developed as an outgrowth of the ambulatory care practice. As patients were often unable to keep office appointments, these patients were seen ad hoc by providers who made visits around office their hours. Since being formalized in 1994, the house call program has grown to a practice of 200 patients, with home visits are limited to the geographic area within a 5-mile radius of the academic center. This program provides ongoing primary care in the home to frail, elderly, urban dwelling individuals. Primary medical problems include dementia, COPD, CHF, Parkinson’s disease, stroke, Diabetes and the many other comorbidities. The majority of patients enrolled in this program are over 80 years of age, female and are eligible for both Medicare and Medicaid. Referrals to the house call program come from ambulatory practices within the health system, emergency rooms, specialized units within the hospital, community agencies such as the Area Agency on Aging (AAA), home health agencies, community and senior centers, family members and patients. New patients are first evaluated by the APN who performs a complete examination, orders needed tests and, with the family, puts into place an initial plan of care. A physician visit is made within 2e4 weeks and patients are than seen every 6 weeks and acutely when needed. Joint visits are made to patients with complex, unstable physical and social needs. Over the course of a year, a patient is seen by the physician 2e4 times and has 6e9 nurse practitioner visits. The core medical team includes 2 nurse practitioners (1.5 FTE), 3 physicians (.3 FTE), one social worker (.5 FTE) and one service coordinator. Other core members include 2 caseworkers from the AAA and 3 nurses from the University of Pennsylvania Health System ’s home health agency, 2 nurses following all non-hospice patients and one hospice registered nurse (RN). Collaborations have been made with podiatrists and optometrists to make home visits and there is the capability for in-home lab draws, diagnostic studies including EKGs, CXRs, echocardiograms, and ultrasound studies. Reimbursement for APN visits comes from Medicare (both fee for service and managed care). Most, but not all, patients are so frail as to require the ongoing, complex, coordinated care from this full interagency team. For these patients, ElderPAC (Elder Partnership for All-inclusive Care) combines home and community-based services provided through the AAA with medical care from the integrated academic health system. Weekly team meetings with the core medical team and nursing staff and monthly meetings with the area on aging caseworkers as well as daily phone, email and texting provide the communication glue that holds the team together. The team members housed in the medical school use an electronic medical record that enables providers to have access to information when a patient is seen by another provider or is being evaluated in the emergency room. Lack of interoperability of EMRs with the other EPAC partners (including the health system’s own home health agency) remains a limitation. Over the course of the past decade, we’ve conducted 2 evaluations of our ElderPAC program to address the question if an interagency interdisciplinary team providing comprehensive, all inclusive care could (a) Increase the share of total survival spent in the community for frail elders, and (b) Reduce Medicaid nursing home costs by providing home- and community-based
care to frail elders. Using either a case control analysis or costs compared to home- and community-based care predicted Medicare costs, ElderPAC has shown a 50% reduction in Medicare costs over the past 10 years. Medicaid spending was reduced by 24%, driven by a 80% reduction in the share of time spent in nursing facilities among EPAC patients. ElderPAC consumers had a 40% increase in community survival, compared to traditional HCBS participants. At the end of the 5-year evaluation period, over 38% of EPAC consumers were still alive in the community, compared to 20% of traditional HCBS consumers. These outcomes are comparable to those of similar PACE programs.13 Table 1 has a list of comparable outcomes for EPAC and traditional waiver consumers. The range of savings compared to the predicted total Medicare costs was from 37 to 48%, depending upon the baseline used for projection. Table 1 Comparable outcomes for EPAC and traditional waiver programs.
Hospital Long-term nursing home Community survival/5-year survival Medicaid cost yr/5 yr HCBS/NH (PBPM) Est. mean HCC annual/5-yr total Medicare savings annual/5-yr total @ .48 @ .37
E-PAC 2 (2004e2009) (N ¼ 92/4360 member months)
Waiver/options controls (N ¼ 216/6910 membermonths)
3.8/100 mm 5.9% 38%/43% $20,640/$7.5 M $1448/$271 3.55 $41,962/ $15.3 M
7.2/100 mm 24.9% 20%/28% $27,084/9.8 M $1084/$1172 n/a n/a
$20,054/$7.22 M $15,458/$5.5 M
The Schnabel in-home program was recently selected to participate in CMS’ Independence at Home demonstration project as a member of the Mid-Atlantic consortium. Independence at Home is an effort to provide for multidisciplinary patienteprovider centered care, integrated across sites of health care, and over time, with a funding mechanism to reinforce such care, in the free for service Medicare world. References 1. Wieland D, Kinsoian B, Stallard E, et al. Does Medicaid pay more to a Program of All-Inclusive Care for the Elderly (PACE) than for fee-for-service long term care? J Gerontol A Biol Sci Med Sci. 2012. http://dx.doi.org/10.1093/Gerona/gls137. 2. Wieland D, Boland R, Baskins J, et al. Five year survival in a program of all-inclusive care for elderly compared with alternative institutional and home and community based care. J Gerontol A Biol Sci Med Sci. 2010. doi:10.1093/Gerona/glq040. 3. Meret-Hanke L. Effects of the program of all-inclusive care for the elderly on hospital use. Gerontologist. 2011. http://dx.doi. org/10.1093/geront/gnr040.
Interprofessional education and practice Debra Bakerjian, PhD, RN, FNP
We have all been hearing the importance of interprofessional education and practice over the last several years. The IOM Report,
GAPNA Section / Geriatric Nursing 34 (2013) 162e165
Future on Nursing1 and the World Health Organization, Framework for action on interprofessional education and collaborative practice2 are just two examples of recent reports highlighting the importance of focusing on improving our fragmented system of health care and inefficient use of our current workforce. Each of these important reports highlights key messages that focus on the importance of starting the discussion of collaboration and interdisciplinary teams early in the education process. Educators can be role models for how this can be done by collaborating with other disciplines in the classroom, bringing the interdisciplinary team together for case studies, and providing the environment for students to challenge the status quo. Additionally, competencies related to interprofessional education and practice3 and team science4 are readily available as resources. As Advanced Practice Nurses (APNs), we all should be examining our own practices based on the expert recommendations. In the classroom, that may mean integrating the interprofessional competencies into our course work as well as bring teams together to co-teach students and teaching students about team science. In practice, it means working together to develop better and more efficient models of care delivery that maximizes the use of the entire interprofessional team, discarding old belief systems that maintain rigid boundaries of who provide care
165
based historical turf, and being willing to change our own behaviors. Being familiar with the interprofessional literature and expert discussion on team science is an important start toward changing practice.
References 1 Institute of Medicine. The Future of Nursing: Leading Change, Advancing Health. 2010. http://www.iom.edu/Reports/2010/ The-Future-of-Nursing-Leading-Change-Advancing-Health.aspx. Accessed 14.01.13. 2 World Health Organization. Framework for Action on Interprofessional Education & Collaborative Practice (WHO/HRH/ HPN/10.3). 2010. http://www.who.int/hrh/resources/framework_ action/en/. Accessed 14.01.13. 3 Interprofessional Education Collaborative. Core Competencies for Interprofessional Collaborative Practice. 2011. http://www. aacn.nche.edu/education-resources/ipecreport.pdf. Accessed 14.01.13. 4 Josiah Macy Jr Foundation. Conference on Interprofessional Education. 2012. http://macyfoundation.org/docs/macy_pubs/ JMF_IPE_book_web.pdf. Accessed 14.01.13.