March/April 2015

Developing an Assisted Living Practice
By Leslie L. Ledbetter, DNP, RN, AGPCNP-BC
Today's Geriatric Medicine
Vol. 8 No. 2 P. 8

Assisted living facilities (ALFs) are recognized as one of the most rapidly growing sectors in health care, with an estimated 1.4 million elderly adults currently residing in ALFs.1 More than 33,000 of these facilities currently operational may be unable to meet the demands of the aging population, expected to increase to 19 million people aged 85 and older by 2050.2 These statistics should prompt particular interest in the medical community in light of the lack of access to direct health care among this population.

This deficit occurs for several reasons: patients' decreased ambulation, lack of transportation, and fewer available resources. ALFs open a relatively low-overhead market to providers—one that is emotionally and financially rewarding. Extending primary care services to ALFs offers direct access to a provider without inconvenience to the patient. Additionally, providers can order labs, X-rays, and other diagnostic testing to be completed at the patient's bedside.

This all-inclusive access to health care services is reminiscent of physicians who performed house calls. Advances in technology and health information have made the ALF provider role increasingly popular. It is both possible and profitable for a provider to start a practice in an ALF. In fact, Medicare and private insurance companies underscore this concept through reimbursement at a higher rate for "home visits" than for in-clinic encounters.3

By definition, these visits are considered home visits or house calls because the patient lives within an apartment, yet has access to nurses and caregivers to aid with medications and activities of daily living. These ALF visits are typically reimbursed by a third-party payer; however, for those who qualify for Medicare Part B, any "medically necessary visit" will be reimbursed.4

Getting Started
Launching a practice in this environment is not without its challenges, but I have created direct patient access to quality health care while generating a revenue source for my company, IPC, The Hospitalist Company. While this medical group focuses mainly on acute and postacute care settings, it has extended primary care services to patients discharged to ALFs, which has evolved into the development of my role as primary care provider (PCP) for most of the patients within the facilities because of their inability to transport themselves to an outside PCP's office.

Research on initiating PCP services in the ALF identified the tremendous need facing both patients and facilities. Developing a philosophy and operational framework is essential to providing consistent, quality care within ALFs and guiding my practice toward becoming an advantageous and cost-effective asset to IPC.

The foundation on which I have based my practice is the concept that the facility (ie, nurses, caregivers, schedulers, executive directors, and administrative personnel) is as important as the patient and his or her family's needs. Balancing the two entities requires meticulous organizational and communication skills, along with some creativity. The patient cannot receive quality care if the facility is unable to follow through with orders or recommendations. This often necessitates meetings with nurses, executive directors, and other administrative personnel to provide a better patient care environment. Facilities are typically open and receptive to education on ways they can alter conditions to enhance patient safety and accommodate provider needs. ALF administrators understand that an in-house provider offers a major advantage in garnering referral clients to the facility because of patients' close relationship with and access to a medical practitioner.

While focusing on the medical priorities of the ALF is imperative, it is equally important to manage and treat patient conditions and diseases. In general, the geriatric population is comprised of patients with multiple chronic health issues that require frequent monitoring to prevent hospital readmissions. Providers may assume that patients in an ALF require only one visit per month, based on the fact that these patients are typically high functioning and require little direct care. However, I have discovered that approximately 30% to 40% of my current patient population requires more frequent care because of their comorbid conditions. Offering direct follow-up care to patients has created a trusting relationship among the ALF personnel, patients, families, and me and has allowed for continued growth through increased admissions and facility growth, as well as a profitable and lucrative expansion.

Associated Considerations
Building patient encounters in an ALF requires constant communication with the facility. Upon admission to an ALF, a new resident is offered the choice of continuing to see his or her PCP or opting to be followed by an in-house provider. If leaving the ALF to visit the PCP becomes problematic, a patient is likely to choose in-house provider services. From that point, the patient's medical information, history, and medications are assessed and recorded. Each patient is designated a medical chart in the nurses' station at the ALF, and all records are maintained there with easy accessibility to the medical provider. Billing for each patient encounter is completed through IPC, The Hospitalists Virtual Office online, and the insurance is billed according to the level of visit performed.

Completing PCP services in the ALF requires some creativity in the absence of exam tables and other equipment typically found in a traditional examination room. A patient's couch or bed is usually where the full assessment occurs, and improvising for various exam techniques is a learned skill. I rely largely on staff nurses and caregivers for full reports on how patients are feeling, especially in light of many residents' cognitive impairment. For patients requiring blood draws, ultrasounds, or X-rays, the provider can order them as mobile services that can be completed in the patient's room. A patient's medical condition often requires additional nursing care managed through home health services, which can be easily ordered.

For patients and families whose loved ones are entering end-stage disease processes, hospice care is an option. Both home health and hospice nursing visits add invaluable care to my team because they provide additional care and support to both the patient and the family, as well as offering constant direct communication regarding a patient's possibly worsening condition, thus warranting a medically necessary visit.

While this type of practice is highly rewarding, it is certainly not without its unique challenges. Time efficiency and medication-related issues present two major barriers to working in ALFs. The time required to complete a full patient assessment in a patient's room typically exceeds that required at the PCP office site.4 Because many patients enjoy interacting with other residents, searching for and locating a patient requires extra time. Additionally, a provider usually travels to several ALFs; therefore, time calculations require allowance for mileage to and from each site.

Medication-related issues can become challenging because ALFs differ in the ways medications are managed and dispensed to patients. Most ALFs have licensed caregivers administer ordered medications; however, others may have unlicensed staff perform these duties. Similarly, some sites permit nurses to receive verbal orders, while others require a handwritten and signed order. It is imperative that the provider becomes familiar with each facility and related guidelines.

Developing a practice in an ALF has been not only a very rewarding experience but also a constant motivator to become a better and more creative clinician. With the burgeoning aging population and increasing numbers of patients entering ALFs, I've discovered the importance of focusing my attention on the needs of both the patients and the facility. Advances in medical technology and mobile health services enable me to provide a fully functioning primary care service at the convenience of patients and families. PCP visits are highly reimbursable, and with essentially low overhead expenditure, the revenue is ideal for a mobile practitioner.

The vast difference from other health sectors requires a provider's patience and the development of a framework that focuses on evidence-based practice, professional excellence, clear communication, facility resources, coordination of care, and fostering relationships with patients and facilities. Meticulous attention to each of these aspects has cultivated a cost-effective and fruitful practice that produces consistent quality health care for a population that experiences increasing barriers and access to practitioners.

— Leslie L. Ledbetter, DNP, RN, AGPCNP-BC, is a geriatric nurse practitioner for IPC, The Hospitalist Company in Tucson, Arizona, and specializes in primary care in assisted living communities. She is also cofaculty for Arizona State University in the College of Nursing and Health Innovation's Doctor of Nursing Practice program.

References
1. Maguire SR. The nurse practitioner in assisted living communities: a role poised for growth. Advance Healthcare Network website. http://nurse-practitioners-and-physician-assistants.advanceweb.com/Article/The-Nurse-Practitioner-in-Assisted-Living-Communities.aspx. March 1, 2008. Accessed July 4, 2014.

2. America's growing elderly population. National Center on Elder Abuse, Administration on Aging website. http://www.ncea.aoa.gov/Library/Data/index.aspx. Accessed July 4, 2014.

3. Young M. Can house calls increase your revenue? Power Your Practice website. http://www.poweryourpractice.com/practice-management/could-house-calls-increase-your-revenue/. Accessed July 4, 2014.

4. Holcomb LO, Wink DM. Nuts and bolts of NP practice in assisted living facilities. J Am Acad Nurse Pract. 2002;14(6):257-260.