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APRNs in Nursing Homes Can Curb Avoidable Hospitalizations

By Jamie Santa Cruz

APRNs' ability to assess nursing home residents' changes in health status early and implement appropriate treatments can reduce unnecessary hospital admissions.

Hospitalization of nursing home residents is common: Each year, approximately one-quarter of all long-stay residents in the United States are hospitalized.1 Many such hospitalizations are preventable.2-4 New research from the University of Missouri has identified a strategy for reducing hospitalizations that appears to be particularly promising—namely, embedding a full-time advanced practice registered nurse (APRN) in the nursing facility.5

Specifically, the researchers found that within four years after the introduction of a full-time APRN into each nursing facility in the study, avoidable hospitalizations had dropped by an average of 34.5%, translating to a 9.3% reduction in residents' overall risk of hospitalization.

"With the APRNs there—more closely evaluating the residents as they have changes of condition and helping to intervene more quickly in response to those changes—things don't get so far out of range. [Residents] don't get so acutely ill, so they can be better managed in the home and avoid that hospitalization," says Marilyn Rantz, PhD, RN, FAAN, a professor in the Sinclair School of Nursing at Missouri University and lead researcher for the Missouri Quality Initiative for Nursing Homes (MOQI), one of seven different projects in various states being sponsored by the Centers for Medicare & Medicaid Services as part of its Initiative to Reduce Avoidable Hospital Admissions.

Not only did the presence of APRNs reduce the likelihood of hospitalization, but their presence also resulted in lower costs: Medicare expenditures for all-cause hospitalization fell by more than $1,300 per resident after the arrival of the APRNs in each nursing facility.5

Problem of Avoidable Hospitalizations
Avoiding hospitalizations among nursing home residents is important due to the negative impact hospitalization has on residents, Rantz says. "It's really, really hard on older adults being transferred from their familiar surroundings to the hospital," she says.

Hospitalized residents face an increased risk of complications and frequently experience functional decline as a result of the hospitalization.6-8 Regaining prehospitalization levels of function is difficult, Rantz says. "For every day that you're lying around in a bed, you're going to spend a week trying to get that strength back."

But the hospitalizations nursing home residents experience are often unnecessary. According to Rantz, previous research has found that a handful of diagnoses—including pneumonia, congestive heart failure, COPD and asthma, urinary tract infections, dehydration, skin ulcers, and falls—account for the vast majority of all transfers. With early recognition and proper intervention, she says, "most of those conditions can be readily managed within the nursing home."

Dehydration, for example, is an obviously preventable cause of hospitalization. "That's the No. 1 reason for having … a change in one's health condition—people get dehydrated," Rantz says. "It's very common with older people. You can correct a lot of problems—including pneumonia—if you get on the dehydration really quickly."

According to Marcia Flesner, PhD, RN, a clinical instructor at the Sinclair School of Nursing at Missouri University and another of the researchers involved in the study, problems with hydration frequently arise from the fact that in many nursing facilities, staff deliver water to residents without taking the extra step of making sure residents are drinking it. But addressing hydration is a basic nursing skill, she adds, and the issue can be corrected within the nursing facility. Instead of relying on a hospital transfer, nursing facilities simply need a plan in place within the facility to ensure residents are receiving necessary fluids.

How APRNs Achieve Results
In the Missouri initiative, a single full-time APRN was introduced into each of the 16 St. Louis-area nursing home facilities involved in the study. The APRNs' explicit purpose was to work with existing staff and with the residents' primary care providers to improve the recognition, assessment, and management of the conditions most commonly resulting in hospitalization.

APRNs were chosen for the intervention over registered nurses or lower-level care providers because they have a higher level of education and are therefore well equipped to recognize illness early on and intervene effectively.

The category of APRN includes nurse practitioners, nurse anesthetists, and clinical nurse specialists, but regardless of their specialization, all APRNs have a master's degree at minimum. The American Association of Colleges of Nursing has recommended that all APRNs in the future should have a doctorate in nursing practice.9

"The APRNs with their graduate education—master's degrees, doctorate degrees—are skilled practitioners who can assess conditions well [and] figure out what's really going on," Rantz says. Depending on state regulations, APRNs can also initiate some treatments.

A key aspect of the APRNs' role was to provide direct care to residents; however, another important function was to mentor and educate existing nursing staff—specifically about how to recognize signs of illness at an early stage, intervene early, and manage the illness within the nursing home setting. This educational role was significant, Flesner says, because much of the work of reducing hospital admissions is a matter of changing the culture of the nursing facility—namely, by promoting the idea that it is best for residents to receive care within the facility rather than in a hospital, and then teaching care providers how to accomplish that goal. "It was a change in a lot of people's minds," Flesner says. "In the beginning, 25% of [the APRN's] job was spent educating the nurses and the aides to learn a new way of working with the elderly so that these transfers could be prevented."

With respect to education of existing nursing staff, the APRNs in the intervention were trained to teach tools available through INTERACT (Interventions to Reduce Acute Care Transfers), a quality improvement program that focuses on improving the identification and management of changes in the conditions of nursing home residents. One important INTERACT tool that was emphasized in the Missouri initiative, for instance, is the SBAR communication form, which calls on care providers to address the following:

situation (reporting a specific change in a resident's condition);
background (ie, note the resident's vital sign readings and give a multifaceted evaluation of the patient's state);
 appearance (provide a description on evaluation); and
review and notify the resident's primary care physician.

Prior to the intervention, Flesner says, assessments such as those conducted in the SBAR approach were very foreign in nursing facilities. "The long term care approach was, 'When in doubt, ship them out.' We had to change that culture."

According to Flesner, the APRNs' presence in the nursing facility full time, as opposed to part time or intermittently, was a significant factor in the initiative's success to date. Being in the facility full time, she says, means that an APRN becomes very familiar with residents and is therefore in a position to detect the small behavioral changes that serve as indicators of early-stage illness in older adults. "They can really be alert to subtle functional changes—namely declines—in the behaviors in the residents. It could be as simple as 'Mary doesn't want to get out of bed today,' 'Mary ate only half of her lunch,' or 'Mary doesn't want to go to the activity room today,'" Flesner says. Such sensitivity to residents' changes in condition, she says, would not be possible for a caregiver who wasn't spending as much time in the facility.

Benefits Achieved Despite Missouri's APRN Practice Restrictions
Significantly, Flesner says, the improvements APRNs achieved in the Missouri initiative came despite the fact that the state of Missouri places significant restrictions on APRNs' practice. States are categorized as red, yellow, or green based on the restrictiveness of their regulation regarding APRNs; Missouri is currently in the red category, representing the strictest level of regulation. Thus, for example, APRNs in Missouri are prohibited from diagnosing or prescribing without a collaborative practice arrangement with a physician and they are limited in how much treatment they can initiate.

According to Flesner, the intervention might have shown even more meaningful results in a state with a less restrictive practice environment, but the fact that the intervention produced such significant results even in a restrictive state like Missouri is a testament to how valuable APRNs are.

Call for Increased APRN Presence in Nursing Facilities
Given the project's success to date, Flesner believes that nursing homes across the country should work toward incorporating more APRNs in their facilities.

"We believe that every nursing home in America should have an APRN who works full time at the nursing home," she says. The population in nursing homes is very frail and vulnerable; there are multiple diagnoses that need management by well prepared and educated people. APRNs are that group of people.

"There's a doctor shortage in America, and the [APRNs] are there. They can do 80% of the care that doctors can do. We have this wonderful resource in America and we need to use it," Flesner says.

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

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9. Frequently asked questions. American Association of Colleges of Nursing website. http://www.aacn.nche.edu/dnp/about/frequently-asked-questions. Updated May 29, 2012. Accessed April 22, 2017.