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More Non-Doctors Providing US Nursing Home Healthcare

July 14, 2017

By Carolyn Crist

(Reuters Health) - As the U.S. healthcare system grows to accommodate more aging patients, nursing home care is increasingly being delivered by specialized nurses and physician assistants, according to a recent study.

In the past decade, the number of doctors in nursing homes has dropped as the number of “skilled nursing facility specialists” has almost doubled, the researchers reported online June 26 in JAMA Internal Medicine.

Whether this trend is a good one isn't clear, the authors write.

“Medicare was created more than 40 years ago around farmers who had problems with access to hernia care. Now our focus is on frail older women with chronic illnesses,” said lead author Dr. Joan Teno of the Cambia Palliative Care Center of Excellence at the University of Washington in Seattle.

“The patients often have functional impairments and need skilled help,” she told Reuters Health by phone. Patients also need coordinated care because for each new chronic illness, they often meet new doctors and specialists, which can lead to medical errors, lack of coordination and inefficiency, Teno explained.

“Our current system supports silos of care,” she said. But now healthcare policy experts are pushing for programs that coordinate care, provide consistent staffing for older patients and train nurses for geriatric care.

“What we’re seeing is an emerging set of programs targeting this older cohort. It’s important to start asking what’s best for the patient and family instead of the system.”

Teno and colleagues used national Medicare Part B claims from 2007, 2010 and 2014 to identify trends in the numbers of physicians, nurse practitioners and physician assistants working in nursing homes or skilled nursing facilities.

The research team found that the proportion of physicians who had ever billed for care delivered in these facilities fell from 13.7 percent to 9.8 percent. Although the number of physicians classified as skilled nursing facility specialists rose from 1,496 to 2,225, that represented an increase from just 0.3 percent of all physicians to 0.5 percent.

Nurse practitioners and physician assistants classified as nursing facility specialists nearly doubled in number from 1,678 to 3,074 during the study period, but because more people entered these professions in general, that did not represent an increase in the proportions specializing in nursing home care.

The proportion of total billing for care at skilled nursing facilities by non-doctor specialists rose from 22 percent to 31.5 percent, though this varied by state, the authors note. It reached nearly 50 percent in Delaware, Hawaii, Tennessee, Connecticut and Massachusetts.

“There have been broad concerns at the national level about the quality of care at nursing homes,” said Dr. Mitchell Katz, director of the Los Angeles County Health Agency, who wrote an editor’s note accompanying the study.

“One of the problems is that many nursing homes have no regular doctors, since it is not a requirement,” he told Reuters Health by email. “Most nursing home patients have a private doctor who signs the orders for the nursing care, but it is at an office where they may not be able to get to the nursing home on a regular basis.”

In an ideal world, primary care doctors would follow their patients from the office to the hospital and to the nursing home, Katz writes in the journal.

“Even if we ramped up the training by several factors in medical schools, we couldn’t meet the need for geriatrics or palliative care today,” Teno said.

A limitation of the current study is that it doesn’t examine quality of care. Future research should investigate whether this growing trend meets the needs of nursing home patients, Katz said.

“My take-home for patients who are frail is to name a good proxy decision maker who can be your advocate, take careful notes, and make sure your health care is coordinated,” Teno said. “We’re keeping our fingers crossed that these new trends will lead to better quality of care.”


JAMA Intern Med 2017.

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