Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2939_Библиотеки_им_академика_М_И_Перельмана
.pdf
Team-Based Care: Nurse Practitioners,
Clinical Nurse Specialists, andPhysician
Assistants
RobertC.Salinas andPeterWinn
Introduction
More than ever before, there is an ongoing national effort to assist older adults attain
and maintain their highest functional status and to successfully age in place. With
the expansion of telemedicine, remote patient monitoring systems, extended home
health care coverage, and emerging home-based primary care models of care, older
adults have the possibility to delay nursing home placement [1]. Residents in nursing facilities and assisted living are often the most vulnerable due to multimorbidities, neurocognitive disorders, and psychosocial issues. The complexity of
resident healthcare and social needs coupled with the increased burden on physicians to provide care in long-term care has increased the need for collaboration
between physicians, the advance nurse practitioners, and physician assistants to
provide interdisciplinary/interprofessional team-based care.
Nurse practitioners (NP) are Registered Nurses who have obtained a Master’s
degree of nursing (MSN) or a clinical doctoral degree as a Doctor of Nursing
Practice (DNP). The DNP was established to acknowledge their professional parity
with pharmacists and physical therapists who have received a clinical doctorate.
R. C. Salinas (*) · P. Winn
Department of Family and Preventive Medicine, The University of Oklahoma, College of
Medicine, Oklahoma City, OK, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_7
93
94
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. C. Salinas and P. Winn
Nurse practitioners with a DNP have had additional education and clinical training
in quality improvement, leadership, and health policy. Nurse practitioners who
practice in nursing facilities are usually designated as a gerontological, adult, adultgerontological, or family NP.Recently the Clinical Nurse Specialist (CNS) education in psychiatric mental health has been changed to that of a psychiatric mental
health nurse practitioner. Nurse practitioners have had greater than 6years of aca-
demic and clinical training [2].
Advanced practice nurses, both nurse practitioners (NP) and clinical nurse
specialists (CNS) have shown improvement in several measures of health and the
behavior of residents in long-term care as well as better family satisfaction [3–5].
The NP and CNS are autonomous and collaborative members of the interdisciplinary team who enhance the accessibility and quality of care in nursing facilities, and
serve as a resource to the assisted living and nursing facility staff who are challenged by the increasingly complex needs of residents [6].
Currently there are over 355,000 NPs licensed in the USA and an increase in
“full-time” NPs from 14% in 2008 to 36% in 2018. NPs now represent 60% of fulltime primary care practitioners in the LTC sector [7]. Nurse practitioners are trained
to perform patient histories and physical exams, to diagnose and treat acute illness,
and to manage chronic conditions; can order and interpret laboratory tests, diagnostic reports such as X-rays, Doppler and cardiac studies; are skilled in primary, secondary, and tertiary prevention; may prescribe medication including controlled
substances dependent on state regulations; and can provide health teaching, anticipatory guidance, and supportive counseling to patients. As of 2022, there were 24
full practice states with practice and licensure law allowing NPs to evaluate patients,
diagnose, order, and interpret diagnostic tests, to initiate and manage treatment,
including prescribing medication (under the licensure authority of the state boards
of nursing). This full practice model has been recommended by the Institute of
Medicine and the National Council of State Boards of Nursing. There are 16 states
with reduced practice, meaning the state practice and licensure law reduces the abil-
ity of NPs to engage independently in at least one element of NP practice. These
reduced practice States require a collaborative agreement with another health discipline (usually a physician) in order for the NP to provide patient care. The remaining
11 states have restricted practice (with state practice and licensure laws) that restrict
the ability of a NP to engage in at least one element of NP practice. Some States
require supervision, delegation or team-management by an outside health entity/
practitioner in order for the NP to provide patient care. Information on which states
has which NP category can be found at https://www.aanp.org/advocacy/state/
state- practice- environment.
It is essential when collaborating with a NP or CNS to have a thorough
understanding of their scope of practice. The Institute of Medicine report The
Future of Nursing: Leading Change, Advancing Health acknowledges that nurses
should practice to the full extent of their education, training and scope of practice in
order to meet our nation’s health care needs and that nurses be full practice partners
with physicians [8].
Team-Based Care: Nurse Practitioners, Clinical Nurse Specialists, and Physician…
95
Partnering withaNurse Practitioner Nurse or
Physician Assistant
Nurse practitioners can achieve better resident health care goals without an increase
in the cost of care. NPs and physician assistants (PAs) who practice in LTC can
reduce hospital admissions and costs [6]. The Evercare (program) has shown that
nursing facilities having a NP manage a resident’s care, had half the number of
hospitalizations than nursing facilities that did not have NP managing the resident’s
care. NPs can improve the quality and accessibility of primary health care services
to this ever-increasing complex resident population through being approachable and
respectful of patient, family, and staff. The nursing staff develops trust with NPs and
value their knowledge. Meta-analysis studies and systematic reviews have demonstrated positive results of NP practice in long-term care:
• High patient satisfaction, decreased hospitalizations, and decreased all-cause
mortality compared to physician alone practice.
• Reduced transfers to the emergency department.
• Lower rates of depression, urinary incontinence, pressure ulcers, use of restraints,
and less aggressive behavior in residents.
• Practice with a high degree of collaboration with the interprofessional team.
• Provide leadership activities that include education of the interdisciplinary staff
in quality improvement, evidence-based practice and practice innovation.
Clinical Nurse Specialists
Clinical Nurse Specialists (CNS) have a Master’s degree in nursing and often have
further specialized training in a particular area of clinical nursing. Though most
frequently employed in Magnet hospitals, they can have a signicant positive impact
when working in post-acute and long-term care. According to recent statistics, there
are 89,000 practicing CNS in the United States [9]. These advanced practice nurses
are experts in the diagnosis and treatment of illness, health promotion, and the
implementation of evidence-based practice. Through education and consultation
with staff, CNS have also been shown to reduce urinary incontinence, pressure
ulcers, aggressive behavior, the use of restraints (both physical and pharmacological), to decrease fall-related injuries, and to improve the effect of cognitively
impaired residents. Adult and gerontological CNSs are expanding practice in wound
care, quality improvement, and education and leadership roles within long-term
care. As noted, psychiatric mental health CNS and NPs are trained in the behavioral
management of persons aficted with dementia and others with serious mental
illness.
96
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. C. Salinas and P. Winn
Physician Assistants
There are over 132,940 physician assistants (PAs) currently working in the USA
and their number is expected to continue to increase [10]. In 2013, a national survey by the American Academy of Physician Assistants, reported that 0.9 % of PAs
were directly employed by a nursing facility or other long-term care facility. PA
training programs are commonly based at medical schools, hospitals, and other
health care facilities. Didactic sessions and clinical rotations are often taken alongside medical students, which helps to cultivate a future collaborative relationship
between these two professions. The rst year of the 26-month PA program covers
the basic medical sciences followed by clinical rotations in all major medical specialties. With over 2000h of clinical and skill training, PAs are well suited to perform patient histories and physical exams, diagnose, order, interpret test results and
manage both acute and chronic conditions, in collaboration with physicians. To be
able to practice a PA must pass the Physician Assistant National Certifying Exam
(PANCE) and require subsequent continuing education in order to recertify every
10years.
A PA’s scope of practice is dened by four domains: education and experience,
state law, facility policy, and the needs of patients. Each is necessary in order to
provide effective patient-centered care. PAs are expected to perform patient care
tasks at a similar skill level and competency as a physician. However, State boards
do not require a PA to be procient in any specic tasks.
Collaboration does not necessarily require the constant presence of a physician.
In fact, in some rural areas a PA can be a patient’s primary care provider with the
supervising physician “checking-in” once or twice a week. The PA’s scope of practice continues to grow, adapting to changes within the medical profession and state
legislatures. It is imperative that the supervising physicians and the long-term care
facility employers be cognizant of changing State regulation.
Prescribing Privileges ofPAs andNPs
A significant difference in prescribing privileges exists between NPs and PAs.
Currently all States allow PAs to prescribe as long as a physician is either
directly involved or available. Most commonly this association is through del-
egation (19 states) and authorization (18 states) with other (13 states) specifying that a physician be directly involved in a supervisory role. Only Arizona has
specified collaboration. In contrast, 24 states allow NPs to have prescriptive
authority where these States have regulations that allow NPs to diagnose and
treat patients independently. The remaining states require varying levels of col-
laboration, delegation, and supervision. Prescribing of scheduled drugs is regulated and enforced by individual States through the Drug Enforcement Agency
(DEA) [2].
Team-Based Care: Nurse Practitioners, Clinical Nurse Specialists, and Physician…
DEA classication of scheduled drugs
Abuse
Schedule Medical use/effects
I • No medical use
• Research use only
II/IIN • Severe psychic or physical
dependence liability
• Narcotic, stimulant,
depressant drugs
III/IIIN • Moderate or low psychical or
physical dependency
IV • Limited psychological or
physical dependency
V • Over the counter or
prescription drugs with
limited amounts of narcotics
• Used for analgesic,
antitussive, antidiarrheal
potential Examples
Highest Heroin, Marihuana, LSD, MDMA
High Narcotic: Opium, Codeine,
Hydromorphone, Methadone,
Hydrocodone
Non-narcotic: Amphetamine,
Methamphetamine, Nabilone
High Narcotic: Acetaminophen with
Codeine, Buprenorphine
Non-narcotic: Ketamine, Anabolic
steroids
Low Chlordiazepoxide, Diazepam,
Barbital, Phenobarbital, Clorazepate,
Alprazolam
Lowest Buprenorphine, Propylhexedrine
97
Controlled (scheduled) drug prescribing is allowed for PAs in the majority of
states through their collaborative practice with physicians. However, 15 states
restrict this privilege to schedule III–V drugs. Florida and Kentucky do not allow for
any controlled drugs to be prescribed by a PA. All states (except for Florida) allow
NPs to prescribe controlled substances: the majority of states allow Schedule II
through V; however, eight states restrict this to Schedule III through V.
The registration procedure with the DEA is the same for all Advanced
Practitioners and designated as “mid-level practitioners.” Only after successfully
completing all requirements imposed by the State in which they will practice and
successfully receive a state license are they then able to apply for a DEA registration. Once approved, they will receive a DEA number beginning with “M.”
There is a signicant lack of PAs who practice in long-term care despite 20%
work in primary care. PA programs have shown a propensity for PAs to prefer practice in orthopedics, urgent care, and in-patient care. However, data has shown that
PAs have a favorable attitude toward the elderly and would welcome inclusion of a
rotation in long-term care during their training.
Collaborative Practice
How and when to develop Collaborative Practice Agreements is beyond the scope of
this chapter; however, some general comments are noteworthy. Interprofessional team
care has become the gold standard in post-acute and long-term care. Within this
98
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
R. C. Salinas and P. Winn
model of care, team members include physicians, Advanced Practice Nurses (NPs and
CNS), and PAs. Currently NP and CNS can work independently (depending upon
state regulations), whereas PAs must work in collaboration with a physician. There are
six models of care in collaborative NP/ physician practice at nursing facilities: collaborator, clinician, care coordinator/manager, coach/educator, counselor, and communicator/cheerleader. Combining these models of care can create synergy that positively
affects residents, resident families, facilities, and staff. There are at least seven differ-
ent forms of collaboration in practice (1) NP hired by a physician; (2) NP and physician both employed by the long-term care setting; (3) NP contracted (self-employed)
or employed by an NP practice; (4) NP employed directly by the nursing facility; (5)
NP employed by the payer (e.g., Optum); (6) NP in a specialty collaborative practice
that includes consulting; and (7) NP in independent practice employs a physician.
It is encouraging to see the progress that has been made in acknowledging the
crucial role that advanced practitioners play in the realm of long-term care and geriatric practice. In 2014, AMDA—The Society for Post-Acute and Long-Term Care
Medicine, House of Delegates, voted to permit full membership to NPs and PAs.
This resolution allows NPs and PAs to be elected to Board positions and the House
of Delegates and thus contribute their expertise to improving patient care [2, 11–13].
Resources for developing collaborative practice agreements can be found
through professional organizations including AMDA—The Society of Post-Acute
and Long-Term Care Medicine (www.amda.paltc.org), the Gerontological Advanced
Practice Nurses Association (www.gapna.org), the American Association of Nurse
Practitioners (www.aanp.org), and American Academy of Physician Assistants
(www.aapa.org).
Pearls for the Practitioner
• Nurse practitioners and clinical nurse specialists are autonomous and collaborative
members of the interprofessional team in both post-acute and long-term care
settings.
• Nurse practitioners’ scope of practice ranges from state to state: full practice,
reduced practice, and restricted practice.
• Physician assistants’ scope of practice is determined by education/training,
experience, state law, and facility policy.
• Prescribing privileges differ between NPs and PAs and from State to State.
• The DEA designates NPs and PAs as “mid-level practitioners.”
• Collaborative practice agreements are often necessary for NPs, CNSs, and PAs.
References
1. Cacchione ZC, Shah R Nurse practitioners, clinical nurse specialists, and physician assistants.
In: Fenstemacher P, Winn P, editiors. Post-acute and long-term medicine: a pocket guide. 2nd
ed. Humana Press. 2016.
2. American Association of Nurse Practitioners. 2022 nurse practitioner state practice
environment. 2022. https://www.aanp.org/advocacy/advocacy- resource/position- statements/
scope- of- practice- for- nurse- practitioners. Accessed 26 July 2022.
Team-Based Care: Nurse Practitioners, Clinical Nurse Specialists, and Physician…
3. Bakerjian D.Care of nursing home residents by advanced practice nurses. A review of the literature.
Res Gerontol Nurs. 2008;1(3):177–85. https://doi.org/10.3928/00220124- 20091301- 01.
4. Bergman-Evans B. Out of the shadows: nurse practitioner leadership in skilled
and long-term care facilities. J Gerontol Nurs. 2021;47(8):3–6. https://doi.
org/10.3928/00989134- 20210707- 01.
5. Rantz MJ, Birtley NM, Flesner M, etal. Call to action: APRNs in U.S. nursing homes to
improve care and reduce costs. Nurs Outlook. 2017;65(6):689–96. https://doi.org/10.1016/j.
outlook.2017.08.011.
6. Katz PR, Ryskina D, Saliba D, etal. Medical care delivery in U.S. nursing homes: current and
future practice. Gerontologist. 2021;61(4):595–604. https://doi.org/10.1093/geront/gnaa141.
7. McGilton KS, Bowers BJ, Resnick B.The future includes nurse practitioner models of care in
the long-term care sector. J Am Med Dir Assoc. 2022;23(2):197–200. https://doi.org/10.1016/j.
jamda.2021.12.003.
8. The future of nursing: leading change, advancing health. Institute of Medicine (US) Committee
on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, at the Institute
of Medicine. Washington, DC: National Academies Press (US). 2011. Accessed 26 July 2022.
9. Reed SM, Arbet J, Staubli L.Clinical nurse specialists in the United States registered with a
national provider identier. Clin Nurse Spec. 2021;35(3):119–28.
10. American Medical Association—Advocacy Resource Center. Physician assistant scope of
practice. 2018. https://www.ama- assn.org/sites/ama- assn.org/les/corp/media- browser/public/
arc- public/state- law- physician- assistant- scope- practice.pdf. Accessed 26 July 2022.
11. Pakizegee, M and Stefanacci R.The ever-expanding role of nurse practitioners in LTC.Ann
Long-Term Care. 2019. Accessed 10 Aug 2022.
12. The future of nursing: leading change, advancing health. 2019. National Academies Sciences
Engineering Medicine. Accessed 10 Aug 2022.
13. Stucky CH, Brown WJ, Stucky MG. COVID 19: an unprecedented opportunity for nurse
practitioners to reform healthcare and advocate for permanent full practice authority. Nurs
Forum. 2021;56:222–7.
99
Common Clinical Conditions inPost-Acute
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
andLong-Term Care
NaushiraPandya
Introduction
The management of medical conditions in the frail elderly who reside in post-acute
and long-term care facilities (PALTC) can be challenging due to multimorbidity,
progressive functional decline, psychosocial issues, and reduced life expectancy.
This chapter will review some of the common clinical conditions that frequently
occur in patients in the post-acute and LTC continuum. The treatments prescribed
and treatment goals often differ from those of patients in other settings, and thus
require an approach that balances the risks/benets of treatment guided by clinician
discussions with the patient and/or surrogate decision-maker. These conditions will
be reviewed in the following order:
• Hypertension
• Heart failure
• COPD
• Diabetes
• Anemia
• Thyroid disorders
• B12 deciency
• Clostridioides difcile infections
• Scabies
• Herpes Zoster
• Acute kidney injury
N. Pandya (*)
Department of Geriatrics, Nova Southeastern University, Kiran C Patel College of
Osteopathic Medicine, Fort Lauderdale, FL, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_8
101
102
N. Pandya
Hypertension
The ACC/AHA 2017 [1] guidelines categorize normal BP as <120/<80 and hypertension dened as a blood pressure >130/80mmHg (see Table1). Hypertension is
the most prevalent and modiable risk factor for cardiovascular disease and death.
The National Health and Nutritional Examination Survey (NHANES), reported the
prevalence of HTN in those >65years to be 63.6% in women and 65.8% in men. In
those >75years, the prevalence is 73.4% in women and 81.2% in men. The ageadjusted prevalence is highest in non-Hispanic black men and women. Up to twothirds of nursing home patients have HTN.In addition to the well-ascribed risk
factors for stroke and cardiovascular disease, persons with HTN are also at increased
risk for atrial brillation, congestive heart failure (CHF), peripheral arterial disease
(PAD), chronic kidney disease (CKD), and cognitive impairment. In older adults,
cardiovascular morbidity and mortality have been shown to progressively increase
as the systolic blood pressure increases.
Although hypertension (HTN) is not a normal part of aging, its prevalence
increases steadily with advancing age. Physiologic changes of aging that contribute
to elevated blood pressure include increased arterial stiffness, increased activity of
the sympathetic nervous system, increased peripheral resistance, and reduced vascular compliance and vasodilation. In addition, changes in the renin-angiotensin
system and kidney function lead to increased salt sensitivity. Obesity and insulin
resistance are also contributing factors. Systolic HTN is highly prevalent, more
common than diastolic HTN and more closely related to cardiovascular risk than
diastolic HTN.
Table 1 HTN denitions and treatment targets– JNC-8 and 2017 ACC/AHA guidelines [1]
JNC-8 2017 AHA/ACC
Denition of
HTN (mmHg)
Elevated
BP treatment
thresholds
(mmHg)
BP targets
(mmHg)
Therapy
selection
Normal <120/<80
Pre-hypertension:120–139/80–89
Stage 1: 140–159/90–99
Stage 2: >160/>100
≥60years old: >150/90
<60years old with diabetes
or CKD: >140/90
>60years old: 150/90
<60years old: 140/90
Non-Black adults, including with DM: rst-line
therapy includes ACE inhibitor/ARB, CCB,
thiazides (alone or in combination)
Black adults, including with DM: rst-line therapy
includes thiazides or CCB
Adults with CKD: rst-line therapy includes ACE
inhibitor/ARB (alone or in combination)
Normal: <120/80
Increased: SBP 120–129
Stage 1: 130–139/80–89
Stage 2: ≥140/≥90
Adults with history of
CVD or ASCVD risk
>10%: >130/80
Adults without history of
CVD and ASCVD risk
<10%: >140/90
<130/80 for all
Non-Black adults:
rst-line therapy includes
thiazides, ACE inhibitor/
ARB, CCB
Black adults: rst-line
therapy includes thiazides
or CCB
Common Clinical Conditions inPost-Acute andLong-Term Care
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
103
In the PALTC setting, blood pressure measurements may not be accurate and
may vary with higher readings in the morning before breakfast and drops after
meals. Post-prandial hypotension occurrs in one-third of patients and is a risk factor
for falls, syncope, stroke, and overall mortality.
Benets andRisks ofTreatment
The benets of treating HTN in the elderly to reduce cardiovascular and cerebrovascular morbidity and mortality is well established, even in those >80 years old.
However, there is insufcient evidence regarding what is the safest and most benecial treatment strategy for frail older adults.
The Cochrane Review on the treatment of essential HTN in elderly patients (15
trials with 24,055 subjects ≥60years) reported a reduction in total mortality (RR
0.90) and a reduction in total cardiovascular morbidity and mortality (RR 0.72). In
very elderly patients ≥80years, the reduction in total cardiovascular mortality and
morbidity was similar (RR 0.75). However, there was no reduction in total mortality,
(RR 1.01) [2]. The benet of antihypertensive treatment in patients age 80years and
older has also been demonstrated by the Hypertension in the Very Elderly (HYVET)
trial in which 3845 healthy community individuals over age 80years with a sustained SBP of ≥160mmHg were randomized to indapamide or placebo with the
addition of perindopril or placebo to achieve a SBP goal of 150mmHg. However,
individuals with immobility, cognitive impairment, and nursing facility residents
were excluded from this study. The benets of treatment were apparent at 1year,
and further increased at 2years, with a 30% reduction in the incidence of fatal or
nonfatal stroke, a 39% reduction in fatal stroke, and a 21% reduction in all-cause
mortality [3].
Recently, guidelines for HTN treatment in the elderly have been informed by the
Systolic Blood Pressure Intervention Trial (SPRINT), which studied 9361 ambulatory subjects, mean age 68years with a baseline SBP >130mmHg. Nursing facility
residents, and those with Type 2 diabetes, heart failure, and dementia were excluded.
Treatment goal of <120mmHg was compared to a goal of 140mmHg and showed
a signicant decrease in outcomes for cardiovascular events (HR 0.77), and allcause mortality (HR 0.73) in the intensive treatment group. Subgroup analysis for
those classied as frail or having a slow gait speed, showed similar results. Selfreported syncope was more frequent in the intensive treatment group, but falls and
falls with injuries were similar in both groups, even in those >75years. All participants studied in SPRINT-MIND showed a 19% reduction in mild cognitive impairment (MCI), but not in probable dementia [4]. However, the PARTAGE [5] study of
1127 nursing home subjects >80 years in Europe showed a signicant relation
between SBP <130mmHg and 2 or more BP-lowering medications and a higher
risk of mortality (adjusted HR 1.78; 95% CI 1.34–2.37, both p<0.001).
Other prior randomized trials of HTN treatment in the elderly (SHEP: Systolic
Hypertension in the Elderly Program; STOP: Swedish Trial in Old Patients; Sys-Eur:
Соседние файлы в папке Библиотека им академика М.И. Перельмана