American Society on Aging
71 Stevenson St., Suite 1450
San Francisco, CA 94105-2938
www.asaging.org
info@asaging.org
In Focus
THE FUTURE OF GERIATRIC MEDICINE: A NATIONAL CRISIS LOOMS
Geriatric Nurses Vital To Care
By Mathy Mezey and Priscilla Ebersole
Concern for the care of older adults has always been in the forefront of the nursing profession, though only in the last three decades has geriatrics been defined as a specialty practice arena. The typical nursing school curriculum includes maternity, pediatrics, medical and surgical care, and public health. This formula, based on institutional staffing needs, has been slow to change. But with shifts in population, clientele and service venues, geriatric nursing has been gradually incorporated into the nursing curriculum.
OLDER ADULTS IGNORED
As the site of custodial care, long-term care settings historically have been neglected by nursing and medicine. Until recently, older adults with complex chronic conditions were largely ignored by the health professions and by society at large. Visionaries such as Barbara Lee of the W. K. Kellogg Foundation; Robert N. Butler, first director of the National Institute on Aging; and Linda Aiken of the Robert Wood Johnson Foundation recognized the need and opportunities for improving care. In the early 1980s, teaching nursing homes, along with numerous other nursing home sites, began to experience the benefits that can accrue to older nursing home residents from the use of geriatric nurse practitioners.
Over the past 20 years, with the advent of HMOs, cost-cutting of hospital care, increased surveillance of long-term care institutions by government agencies, and Medicare demonstration projects, the role of geriatric nurse practitioners has expanded and is now integral to the provision of long-term care. Recognized as major service providers in the care of older adults, geriatric nurse practitioners and specialists are trained in graduate nursing programs that include intensive didactic content and interdisciplinary clinical practice experiences. It is thought that approximately 60% of advanced-practice geriatric nurses work in long-term care facilities. These nurses have authority to prescribe medications in all state jurisdictions and receive 85% of the reimbursement rate that Medicare sets for physician services.
Advanced-practice geriatric nurses, working collaboratively with physicians, have been shown to deliver high-quality primary care to frail nursing home residents and to older people in ambulatory-care facilities and hospitals. In long-term care especially, geriatric nurse practitioners improve quality outcomes and limit unnecessary hospital admission through extensive case management, health promotion activities, quick response to changes in the resident's health status, improved immediacy of care, and enhanced training and support for licensed and unlicensed nursing staff. In some homes, advanced-practice nurses are employees of the facility; in others they collaborate with primary care physicians to manage a caseload of residents.
In capitated healthcare models, geriatric nurse practitioners manage nursing home residents in a fiscal environment in which payments for care are capped at a set dollar amount per resident rather than being reimbursed on the basis of ongoing costs. The aim is to reward prevention and early case-finding. Evercare, the largest and longest-established model of capitated care for nursing home residents, created a capitated HMO model that has become an industry standard for enrolling frail nursing home residents and assuming full responsibility for their medical care, including hospitalization. Residents enrolled by Evercare, a national company based in Minneapolis, Minn., are cared for by geriatric nurse practitioners working collaboratively with physicians.
Typically, the nurse practitioner in Evercare spends a good part of a day in the nursing home managing the primary and episodic care of all of the residents enrolled in the program. Thus, the facility gains the service of a nurse practitioner who can respond quickly to changes in a resident's health status and can order diagnostic tests and begin medications and other treatments to prevent deterioration in the resident's condition. The practitioner also is a resource for the nursing staff, conducting bedside rounds and more formal staff education. Capitated HMO systems such as Evercare have the financial resources to provide these additional services because they are able to reduce costly and often unnecessary admission of a resident to the emergency room or the hospital.
Today, the 55 programs that prepare advanced geriatric nurses in colleges and universities in the United States graduate a mean of just five students annually. Since 1991, approximately 4,200 nurses nationally have been certified by the American Nurses Credentialing Centers as advanced-practice geriatric nurses. Because there are so few of them, and because they practice predominantly in institutional long-term care and in urban settings, advanced-practice geriatric nurses cannot hope to serve the healthcare needs of most older adults. Adult and family advanced-practice nurse practitioners--about 37,000 in all--are an untapped pool of healthcare providers for older adults. Many of these nurses function as geriatric nurse practitioners. Ensuring that all advanced-practice nurses who work with older adults have geriatric knowledge and skills would substantially increase older people's access to higher quality geriatric services.
Another important issue in preparing advanced-practice nurses to care for older adults is that nurses practicing today have had very little exposure to the assessment process and symptom management at the core of best practices in geriatrics. A major problem, for example, is a lack of adequate geriatric content in undergraduate nursing education. To ensure that every new graduating nurse and every practicing nurse has the knowledge and skills to provide high-quality care to older adults, the John A. Hartford Foundation Institute for Geriatric Nursing at New York University (www.hartfordign.org) has developed extensive programs and materials that bring a geriatric presence to nursing education and practice.
The much-publicized shortage of nurses in the United States is related to the absence of workplace satisfaction, enormous increase in technologically sophisticated aspects of care, and inadequate compensation for the level of responsibility expected of nurses. Geriatric nurses and geriatric nurse practitioners in long-term care settings are undercompensated by comparison with nurses who work in other settings. Yet the need for geriatric nurses and nurse practitioners will only grow as the population ages. Assisted living and continuing care retirement communities offer new and expanded opportunities for geriatric nursing. In a time of nursing shortage, long-term care settings need strong and innovative agendas if they are to compete with hospitals and ambulatory settings for an adequately prepared nurse workforce. Working together, older adults and families along with nursing educators must create the vision of geriatric nursing as a frontier for higher-quality professional nursing practice.
Mathy Mezey is the Independence Foundation Professor of Nursing Education and director of the John A. Hartford Foundation Institute for Geriatric Nursing, Division of Nursing, New York University, New York City. Priscilla Ebersole, professor emerita at San Francisco State University, is the editor of Geriatric Nursing Journal.
American Society on Aging
71 Stevenson St., Suite 1450
San Francisco, CA 94105-2938
www.asaging.org
info@asaging.org