Monday, September 23, 2013
As they grow older, about 70 million baby boomers will test the mettle of the nation’s healthcare system — particularly its supply of primary care providers — like never before. Will there be enough PCPs to meet boomers’ chronic care needs? Some say no and are working toward securing nurse practitioners’ expanded scope of practice across the county, which will allow NPs to meet the growing need for more providers.
Members of America’s massive generation of baby boomers — people born from Jan. 1, 1946, through Dec. 31, 1964 — are now reaching age 65 at a rate of roughly 10,000 a day. The combination of aging baby boomers and an expected influx of patients seeking healthcare in 2014 under provisions of the Affordable Care Act may provide fodder for nurse practitioners seeking to expand scope-of-practice laws in the 34 states that limit it.
In some states patients can work directly with nurse practitioners who can provide services such as diagnosing, initiating a treatment plan, ordering tests and prescribing medication. Elsewhere, physician involvement is required, and how much involvement varies widely. Tay Kopanos, RN, DNP, FNP, vice president of state government affairs for the American Association of Nurse Practitioners, says her organization’s chief aim is to strike a balance between NPs’ level of education and skill and the amount of care that many existing state laws let them deliver. “We think we can solve a lot of healthcare challenges by closing that gap,” she said, adding that the vast majority of NPs are trained as PCPs, and nearly 70% practice in a primary care setting. “We prepare in primary care and we stay there,” she said.
Physician groups’ opposition to expanding nurses’ scope of practice has been a major hurdle to changing state laws, advocates agree. Nancy O’Rourke, RNC, MSN, ACNP, ANP, Massachusetts state representative for AANP, argues that to make their case, NPs should focus first on data demonstrating their ability and high quality of service, and then show how many healthcare dollars could be saved if NPs were allowed full practice authority. “See who’s going to give you the best bang for your buck,” O’Rourke said. “That’s where the argument is right now, especially in the elderly population and in end-of-life care, because that’s where most of our Medicare dollars are being spent, and that’s where NPs are going to make the most impact, if we’re allowed to.”
In Massachusetts, where a 2006 law established near-universal healthcare, state policymakers have glimpsed what may lie ahead for the nation as new Affordable Care Act patients and baby boomers affect the balance of care. While that state found that a substantial challenge is that young adults were most likely to have fallen through insurance coverage cracks, one of the stiffest challenges has been the management of chronic, complex problems among older adults, O’Rourke said. “The need to do really good chronic care management has stressed the system because we haven’t been good at that in the past,” she said.
Advocates hope that lifting state limits requiring NPs to have physician supervision will help change that. Management of chronic illness is expected to play a larger role with baby boomers than it was for prior generations. By 2030, an estimated six in 10 baby boomers will have more than one chronic condition, according to a 2007 American Hospital Association report. A recent study in JAMA Internal Medicine found that compared with the same age group a generation ago, baby boomers are more likely to be obese, diabetic, hypertensive or requiring a device to assist walking. Only about 13% of the study’s boomers considered themselves in “excellent” health, compared with 32% of the earlier generation.
Patients who receive care from an NP tend to adhere to medication and treatment plans better than patients who see other providers do and therefore need less follow-up treatment, Kopanos said. “Nurse practitioners can really help decrease the burden of chronic disease both on the patient … and the global healthcare system.”
As this generation grows older and sicker, family caregivers also will need more support, said Susan Reinhard, RN, PhD, a senior vice president at AARP and director of its Public Policy Institute. Along with patients, about half of family caregivers, with little training, are performing complex medical or nursing tasks, such as medication management, many of which used to be routinely handled only by nurses or other trained professionals, AARP-supported research has shown.
Reinhard said it’s far too common for patients to be discharged and then expected, with little education, to handle — either on their own or with family caregivers — such things as IVs, oxygen, and wound and colostomy care, often for extended periods. Moreover, family caregivers report believing they must soldier on even when they’re unclear about how to administer specific aspects of care. “They’re doing all this stuff that used to be done only in hospitals and nursing homes, and they’re doing it with such little support it’s almost malpractice, in my opinion,” said Reinhard, who is chief strategist for the Center to Champion Nursing in America at AARP.
Tapping NPs to help fill consumers’ education and support gap simply makes sense, Reinhard added. While physicians aren’t as geared toward teaching patients and families, “NPs have the natural skill set to teach,” she said. “It’s based on nursing preparation and expertise, which is teaching people how to take care of themselves.”
Kopanos agreed that NPs have extensive training in educating and engaging patients and families. “What we’re finding with chronic illness is a patient may engage with their healthcare provider three to eight times a year, 15 to 45 minutes per visit. But the majority of their health and chronic disease management is left up to patients. NPs help them better manage their care.”