Advanced practice RNs improve quality outcomes across the care continuum in multiple ways, including decreasing readmissions.
This article first appeared in the June 2017 issue of HealthLeaders magazine.
Healthcare executives don’t need a crystal ball to predict the current interest in achieving safe, high-quality, cost-effective care that will continue to grow well into the future.
Some organizations, like Englewood, Colorado–based Catholic Health Initiatives, a nonprofit health system with operating revenues of $15.2 billion in fiscal year 2015, have already recognized that a bright future will require them to alter care delivery models to meet the demands of the nation’s changing healthcare system.
"We were beginning to look at what was going to be happening in the future and where we were going and all the different things that we needed to do to increase quality and decrease costs at the same time," says Kathleen D. Sanford, DBA, RN, FACHE, FAAN, senior vice president and chief nursing officer at CHI. "We were also looking at the types of shortages we were going to have in the future, and we figured out that there is no way that we are going to be able to continue doing things the way that we are doing things right now."
To help plot a new path, leaders at CHI compared evidence on quality outcomes of advanced practice practitioners (advanced practice RNs [APRN]—also referred to as APNs—and physician assistants) to quality outcomes of physicians.
A large body of evidence has found that APPs produce quality outcomes similar to or better than physicians. For example, a systemic review of 71 studies published from 1990 to 2009 found that clinical nurse specialists, certified nurse midwives, and nurse practitioners produced quality, financial, and clinical outcomes that were equal to or better than physicians.
At the time it was done, there were not enough studies on certified registered nurse anesthetists that met the criteria to be included in the review. However, newer studies have found that CRNAs and physicians have similar complication and mortality rates, and care by a CRNA did not increase risk of harm to patients.
Based on evidence, CHI made a commitment to strengthen advanced practice across the organization, including hiring Michelle L. Edwards, DNP, APRN, FNP, ACNP, FAANP, as system vice president, advanced practice.
"We want to use more advanced practice practitioners. We want to move into a team care model because everything we looked at said that was where we needed to go if we were truly going to keep people well, as well as take care of them in the hospital, across the care continuum, and as populations," Sanford says.
CHI isn’t alone in recognizing how valuable APRNs can be in affecting clinical, quality, and financial outcomes. Organizations around the country are also increasing their use of APRNs, and some are already seeing quality outcomes improve as a result.
Improved readmission rates
A few years ago, Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name Medical Center was given carte blanche to design a new nursing care model at the organization, a private nonprofit 361-bed acute care hospital in Teaneck, New Jersey. After working with a subcommittee of APNs, she launched the NP Care Model in 2012, a patient-centered collaborative care model.
"The nurse practitioner is the conduit throughout the disciplines in order to make the patient experience and outcomes the very best, and that’s basically how we designed the model. Then we looked at the framework of complementary responsibilities that an APN possesses and what would bring relevance to the program such as, 'What are the opportunities for the physician? What would be the organizational benefit? And is there a return on investment?' " Kutzleb says.
The model’s goals were threefold: Reduce 30-day readmissions by 11% over 12 months, decrease cost per case, and enhance quality patient outcomes through NP-directed patient education on disease self-management.
The program, which originally focused on heart failure patients, far surpassed these initial goals. Over a 12-month period, 30-day readmission rates dropped to 8% from 26%. Healthcare costs for the group of 312 patients receiving care via the NP Care Model was $311,818 during the 30 days after discharge. Prior to its implementation, cost of care for this patient population during the 30 days postdischarge was $1,019,405.
The drop in recidivism went beyond the initial 30-day discharge period. The 60-day and 90-day readmission rates for the group receiving care through the model were 4% and 3% compared to 27% and 29% in a group receiving typical care.
Because of these significant results, the model has expanded beyond heart failure patients, and advanced practice providers are being added to more of the medical center’s service lines, including cardiology, chronic care management, oncology, and genetics. Presently, there are approximately 40 advanced practice providers (including PAs) at Holy Name, up from five in 2009.
Sheryl Slonim, DNP, RN-BC, NEA-BC, APN-C, executive vice president, patient care services and chief nursing officer at Holy Name says her vision is to continue to expand the number and use of APNs at the organization.
"You can’t function in a silo anymore. Care must be managed and coordinated across the continuum, and who better than the APN to help coordinate that?" she says. "What I don’t think people realize are the many different roles and areas where APNs can function. Whether it’s in the home, whether it’s in the community, whether it’s in the hospital, whether it’s in long-term care, whether it’s in subacute, whether it’s in a surgery center, there are so many different roles that the APN can play in so many different environments. Why not take advantage of the role and allow it to help foster the healthcare system that right now is just so confusing to people?"
APRNs at CHI have also delivered strong results in terms of patient outcomes, Edwards says.
In the organization’s Nebraska division, an NP-run program in skilled nursing facilities has grown from three NPs to nine over the past 11 years. Working in collaboration with a physician, the NPs see more than 2,000 unique patients a year, up from 300 when it began. The readmission rates for patients in the program are around 12%, double digits lower than the national hospital readmission rates of 25%.
By working collaboratively with the SNF nursing and therapy staff, the team has been able to identify and resolve barriers that prevent patients from being discharged home. During the first six months of fiscal year 2017, length of stay at the SNFs decreased by 3.68 days—or 8.6%—compared to the same time period the prior year.
Based on a projected volume of over 2,200 unique patient admissions, this reduction in SNF length of stay would result in nearly $2.7 million in savings for fiscal year 2017.
Additionally, no negative effect on clinical outcomes, including hospital readmissions, was seen as a result of the shorter lengths of stay. In fact, the cost-avoidance savings for thwarting preventable rehospitalizations in fiscal year 2016 was $1.8 million.
In a different CHI division, a comparison of NP utilization within the orthopedic group found that patients cared for by orthopedic teams with NPs integrated into the team had lengths of stay that were one day less than orthopedic teams without NPs.
Edwards says performance indicators and metrics—like how often a provider is meeting CMS core measures—should be applicable to APRNs, PAs, and physicians.
"Excellent care is excellent care," she explains.
Challenges to APRN use
Despite the benefits APRNs bring to organizations, there are still challenges about whether they are used to their full potential.
As Edwards points out, granular data collection regarding APRNs is a work in progress.
"Because of CHI’s sheer size, and the various EHR platforms that we have today, we’re still working on trying to establish a process where we’ll have an enterprise view of the APC performance on the various metrics," she says.
CHI employs 1,600 advanced practice providers, operates in 18 states, and has 103 hospitals plus an array of other facilities and services across the inpatient and outpatient continuum, including community health-services organizations, home-health agencies, and living communities.
UK HealthCare, a Level 1 trauma center and academic research institution made up of hospitals and clinics of the University of Kentucky in Lexington, has also seen challenges collecting specific data on APRNs.
"We’re in the process of having a switchover from our data warehouse, so we’ve had a hard time pulling the individual (APRN and PA) data because of the way our system is set up. Our information technology system is evolving to help us pull a lot of those data," says Lacey Troutman Buckler, DNP, RN, ACNP-BC, APRN, NE-BC, assistant chief nurse executive, advanced practice and strategic outreach, and director of cardiovascular nursing services and the office for advanced practice at UK HealthCare.
Another challenge is ensuring standardization of practice, duty, and roles among all APPs across an organization.
In 2008, when UK HealthCare made a move to grow its advanced practice offerings, there were about 80–90 APPs throughout the organization. Buckler embarked on an assessment to better know how and where these practitioners were functioning in the system.
"We were trying to get ourselves prepared because we knew advanced practice would expand in both inpatient and outpatient,” Buckler says. "We wanted to make sure that we had our arms around what advanced practice looked like here, and if we were going to increase that model in the future, how we would do that."
One thing that became apparent was the need for consistency and standardization of practice.
"We had a lot of opportunities to standardize our approach to advanced practice here," Buckler says. "We realized at that point we had lots of great work going on, but we wanted to make sure that there was some way to connect these providers to a professional home that understood what their role was and understood how we could support them in practice."
Hence, the creation of UK HealthCare’s office for advanced practice. The office standardized job descriptions, restructured compensation, and continues to act as a resource for scope-of-practice standards for the organization’s more than 400 APPs.
Vicky Turner, RN, DNP, ACNP-BC, APRN, CCRN, is the former codirector of the office for advanced practice, where she was able help others, including physicians, understand APRNs’ scope of practice.
"It took, and continues to take, a lot of education and reeducation. Nearly every time we meet, I have to say, 'Oh yes, this is within the scope of practice of APRNs,' or 'Oh no, we cannot be doing those kinds of things.' But I have to say this group is very established," Turner says.
Holy Name’s Slonim agrees that education is needed on APN scope of practice.
"I think the biggest barrier is people understanding the role," she says. "Once the public accepts what the APN does and embraces it, then there really isn’t a barrier. Once they grasp the concept of partnership between the APN, the physician, and the patient, that’s when the silos break off, and it just becomes a solid continuum."
And, as Kutzleb points out, solidification of the care team produces the goal everyone is after—better patient care.
"I look at it as a partnership, and in a partnership, if I bring my best to the table, and the physician brings his best to the table ultimately, the patient’s going to win," she says.
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.