[NPInfo] Kudos to NPs and PAs

[David or Diane Dito]

Anne,

In theory, much of what you propose is correct about the potential benefit
of developing relationships with patients and other care entities by
coordinating care and education to bridge the gap.

HOWEVER (and there's always a "however" in life!), this has been studied
fairly extensively, and there are many system barriers that interfere with
implementation of such a proposal.

One thing you might want to read is the American College of Emergency
Physicians' April 2008 report: Emergency Department Crowding: High-Impact
Solutions, which delves into this very thing.

One of the biggest barriers is the fact that except for the ER, just about
all other medicine is carried out on an 8-5, M-F mindset. Unfortunately,
patients don't become ill or need care only during "business" hours.
Therefore, needed tests or studies often are postponed until these times,
creating an uneven patient flow that bottlenecks during nights or weekends
and stops flow. Getting the huge train that is our health-care system moving
at cruising speed, then, is a difficult task that is very inefficient.

Do you currently work in the ER or the hospital setting, Anne? Although it's
a nice dream to imagine a place where NPs are given the resources and time
to provide services ancillary to direct patient evaluation and treatment of
their acute medical needs, it's not going to happen in the near future. The
business of health care demands that we see as many patients as possible in
the shortest time possible to maximize revenues to keep the train going.
Most ERs simply do not make enough money in the present health-care
environment of limited insurance reimbursements and the burgeoning uninsured
population to support NP pay for services that could be provided by others.
And even if the NP were to be given that latitude, I'm not sure it would
make a huge impact on our patient populations, where the present culture has
become that the ER is the be all and end all of health care and that every
patient deserves the latest, greatest, most expensive tests that technology
can provide, regardless of the complaint or insurance status.

I'm by no means dismissing your wonderful thoughts, Anne. However, I work at
a large, inner-city ER where we've studied flow and resources ad nauseum and
implemented strategy after strategy to ease crowding and improve flow to no
avail (yet). We have had in place most of the things you mentioned at one
time or another, including direct patient referral and transfer to a clinic
from triage, a case coordinator and now a paid referral coordinator to
assess patients' needs and make follow-up appointments for them, RN- and
social work-led teaching strategies, ED-based physical therapists who can
evaluate and treat on the spot and refer to their clinic for on-going
therapy, regular communication provider-to-provider between the ED provider
and the pt's PCP via a communications center that places the call for us and
hooks us up directly, evaluation of the benefit of setting up a direct
referral, completely separate clinic for the non-urgent cases, etc. None of
it has made any difference in the growing patient volumes we see. When the
frequent flyers are asked why they didn't follow up with the referred
provider, many point to other social issues that impede appropriate
follow-up (lack of transportation, lack of money, homelessness, etc.) or
personal preference to use the ER, because "this is my doctor." As NPs and
PAs, my colleagues and I have beaten this poor dead horse deeper into its
grave.

Lest I sound too jaded, let me say that I have my dreams, too, of a system
that provides at least basic health care to all individuals, and of
individuals who feel a responsibility to participate in their own health and
care, who forego cigarettes, alcohol and crack cocaine to build a bit of
savings toward their bodies and their own health care funding.

The stark reality is that most EDs simply can't afford to pay an NP to
provide social services to patients when there is meat to move, though I
think you're making the valid point that they can't afford NOT to provide
these services. At my facility (and most others, I think), NPs are not
treated any differently than any other provider in that they are paid and
expected to move the meat. It's crass, but it's true.

The interesting thing about the ACEP study was that by taking the mind-set
that health care is a 24/7 proposition throughout the rest of the hospital,
most ED crowding was found to evaporate. It makes sense when you think about
how much momentum is lost when you allow a huge train to grind to a halt and
then try to force it back to full speed again. And if we did that one thing
alone, I would propose that ALL health care providers would have more time
to educate patients and help coordinate their care better.

Flame away!

Diane Dito 

----Original Message-----
From: npinfo-bounces at nurse.net [mailto:npinfo-bounces at nurse.net] On Behalf
Of Meg
Sent: Friday, May 30, 2008 12:55 PM
To: npinfo at nurse.net
Subject: [NPInfo] Kudos to NPs and PAs


Today, EDs are crowded at levels they've never been before, and there's few
if any signs the problem can be made better. Sure, smart hospitals can
improve patient flow by investing in IT that tracks them efficiently. And
there's always ways to make better use of time when patients are
waiting--for example, I've heard of some that take blood samples and do an
EKG while patients was boarding in the hallway.

But I'd argue that the answer isn't necessarily getting them in and through
the system as quickly as possible--out the door or into beds--isn't
necessarily the best way to think about dealing with this flood of patients.

After all, just because a patient isn't dying (and doesn't need to be
admitted at that moment) doesn't mean that they're a) not just a bit too
acute to be lightly sent home to bed, b) might benefit from palliative meds
to tide them over until specialists can see them, or c) in need of more
information to better self-manage their condition than the more or less
useless handouts EDs typically provide. And that argues strongly for
establishing at least some kind of primary/urgent stepdown presence in the
ED for patients who still need help once it's been determined that they're
not in immediate danger.

For one thing, a primary care-minded staff member such as a nurse
practitioner can do much to help coordinate care between the ED and on-call
staff at primary care practices. He or she can also ask a few probing
questions of the primary care physician to see if there's tests or issues
the patient might not have mentioned, something that ED physicians seldom
has time to do.

What's more, an NP can help develop a slightly more robust care plan for
moving forward than "here's a referral," which all many non-critical
patients get. Such help not only improves outcomes overall, it also builds
relationships with patients who may have a need to return to your ED
someday.

On top of everything else, if hospitals place an urgent care person within
the ED, that could serve as a funnel to future relationships with the
patient and his or her family which could include ambulatory surgery
referrals, relationships with affiliated primary care practices, physical
therapy and more. In other words, while health systems may not get an
admission out of that visit, but they could develop a longer-term
relationship that proves fruitful for both sides.

So, folks, what do you think? Am I on base here? Is there something I'm
missing? Write to me and tell me what you think. -Anne

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