Nurse practitioners (NPs) and physician assistants (PAs) have been in clinical practice since the late 1960s. Yet there are still many misconceptions about scope of practice and the advanced practice provider (APP) role, particularly in post-acute and long-term care (PALTC). Three areas of frequent misconceptions include (1) initial admission visits, (2) legal risks, and (3) patient/resident satisfaction. Let’s take an in-depth look.
Can NPs/PAs Complete Initial Admission Assessments in a Skilled Nursing Facility?
Outdated federal regulations from 1997 state NPs and PAs are not allowed to complete the initial history and physical because they are not delegated to bill the initial admission Current Procedural Terminology (CPT) codes (99304, 99305, and 99306). However, if a new resident is admitted to the facility with an acute issue and the NP or PA is present, they can provide prompt attention and bill for resident care using subsequent visit CPT codes (99307, 99308, and 99309).
With APPs on site at facilities, they can quickly coordinate care to address critical issues that would likely be neglected and improve outcomes (J Am Geriatr Soc 2020;68:892–894; J Adv Nurs 2013:69:2148–2161). Some examples include wound care, acute infections (urinary tract infection), acute exacerbations of atrial fibrillation or heart failure, emergent medication-related issues, or other problems that must be promptly addressed. These visits can be completed and billed as a “transition of care” visit, typically with a CPT code that has an extender for time spent (99356, 99357). Transition of care visits are visits provided by an APP before the physician does the initial admission visit, usually to see the patient/resident and tuck them into the facility.
Once the physician has completed the first admission visit, they are required to perform monthly visits for the first 90 days. During this time, the APP may continue to see the resident if needed as well. After 90 days, the NP or PA can see the resident for every other monthly regulatory visit thereafter (Centers for Medicare & Medicaid Services, “Physician Delegation of Tasks in Skilled Nursing Facilities [SNFs] and Nursing Facilities [NFs] [Memorandum],” Mar. 8, 2013, https://bit.ly/3TU0fvG
). This alternating schedule represents a respectful, wonderfully collaborative team approach to resident-centered care where the residents’ needs are met on a timely basis and visits are coordinated and shared.
Does Having an NP or PA as Part of My Practice Increase My Legal Risk?
Many practices hesitate when considering hiring an NP or PA because of the misconception that NPs/PAs increase the practice’s legal risk. However, NPs and PAs both have low malpractice rates, and fewer than 1% have been named as a primary defendant in a malpractice case. Most NPs and PAs also carry their own medical malpractice insurance.
In a retrospective study reviewing 17 years of medical malpractice claims in the United States, $74 billion was paid out in malpractice claims against physicians, NPs, and PAs (J Med Licensure Discipline 2009;95:6–16). Of that amount, only $245 million was associated with care provided by a PA. PA claims only accounted for 0.003% of the paid-out claims. NP claims accounted for 0.007% of the paid-out claims in this same 17-year span. This same study found that for every 32.5 PA-related malpractice payouts, there was a payout for every 2.7 physicians. Although the study collected data on NPs as well, it included both active and inactive providers. From this they found an incident rate of one payout per 65.8 NPs.
It is common knowledge that the type of relationships formed with residents/patients and their satisfaction with care contribute to the risk of a malpractice claim, which leads us to the last misconception to be addressed.
What Is Resident/Patient Satisfaction With the Care Provided by NPs and PAs?
Resident/patient satisfaction with care impacts a practice’s success. In a systematic scoping review of literature pertaining to satisfaction with PAs, researchers found that patient satisfaction with and acceptance of PAs was largely indistinguishable from their physician colleagues (Hum Resour Health 2019;17:104). A cross sectional national survey that specifically targeted Medicare participants found that patients “are generally satisfied with their medical care and do not distinguish preferences based on type of provider,” where the providers included physicians, NPs, and PAs (JAAPA 2006;19:36,39–40,42–44).
Furthermore, a retrospective observational study of primary care patients found that their satisfaction with NP/PA visits was equal to or slightly better than visits with a physician (Med Care 2004;42:579–590). When the investigators adjusted for patient and visit characteristics, they found that patients were significantly more likely to be more satisfied with NP/PA visits than physician visits in adult medicine practices.
The latter finding appears to be the current trend, which lends to the theory that if individuals’ needs are met and they feel listened to and respected, their satisfaction will be high, independent of provider type.
Where Does the NP/PA Council Fit In?
In 2018, AMDA – The Society for Post-Acute and Long-Term Care Medicine established the NP/PA Advisory Council to improve the inclusivity of the Society’s NP/PA members and recognize their expanding role in PALTC. The advisory council’s mission is to offer insight into the practices, policies, and trends that affect health care involving NPs and PAs, collectively referred to as APP.
Ongoing and often rapid changes in the PALTC setting underpin the need for recommendations, education, and open dialogue regarding collaborative practice, inclusive and appropriate language, and understanding of roles and scopes of practice. The council intends to provide ongoing support and guidance as we work toward more collaboration in the care of our PALTC communities.
The council is committed to helping Society members know and understand their interprofessional colleagues. Any questions regarding the NP/PA roles in PALTC can be presented to the advisory council at [email protected]
The author would like to thank the AMDA NP/PA Advisory Council, including Linda Keilman, Barbara Resnick, Jamyl Walker, Debra Bakerjian, Kim Posey, John Knight, and Cari Levy, for their helpful insights and edits during the process of writing this article.
Ms. Villegas is a physician assistant who works in Denver, Colo., with Longevity Health Plan.
January 11, 2023
In this episode, Dr. Karl Steinberg and Dr. Elizabeth Galik discuss our January-February issue, including the use of alcohol in long-term care communities, misconceptions about nurse practitioners and physician assistants in long-term care, dental hygiene in older adults, and how facilitating better sleep might help prevent cognitive decline.