Is There a Case to Be Made for Nursing Home Specialists?

By Mike Bassett

Studies indicate that clinicians who practice in skilled nursing facilities are becoming specialized and focusing their practices in nursing homes. Does this warrant creating a specialty related to proficiency in this area?

It appears that an increasing number of physicians and advanced practitioners are focusing more of their attention on nursing home care—a trend researchers say represents a new specialty in medical practice.

In a study published in JAMA in November, researchers led by Kira L. Ryskina, MD, an assistant professor at the Perelman School of Medicine at the University of Pennsylvania, found that those physicians, nurse practitioners, and physician assistants focusing on nursing home care increased by more than one-third in the period from 2012 to 2015.

Ryskina and her colleagues analyzed Medicare Part B billing data and determined that of those clinicians who do any work in nursing homes, 21% now specialize in nursing home care—defined as having billed at least 90% of episodes from a nursing home.

In a similar study, published in JAMA Internal Medicine in June 2017, researchers led by Joan Teno, MD, of the Cambia Palliative Care Center of Excellence at the University of Washington, found that over the last decade there has been an increase in the number of health care professionals working exclusively in skilled nursing facilities.

According to the Ryskina study, the number of physicians, nurse practitioners, and physician assistants who met the definition of nursing-home specialists rose from 5,127 in 2012 to 6,857 in 2015, an increase of 33.7%. At the same time, the overall number of clinicians billing from nursing homes was basically unchanged (33,218 to 33,087).

"We were able to see that in general the number of clinicians who do any work in nursing homes doesn't change over time," Ryskina says. "But it appears those clinicians who already practice in nursing homes are becoming specialized and focusing their practices on nursing homes."

What Is Driving This Trend?
Ryskina speculated that there could be a couple of factors at play. "One factor we are looking at is nurse practitioner scope of practice regulations," she says. "And we are finding more nurse practitioners are specializing in nursing home care in states that have less restrictive regulations on scope of practice."

There is also the demand side of the equation. For example, Ryskina says, data show that the nursing home population is getting sicker and requiring more of a presence by clinicians. "There are no hard answers yet," she adds, "but we are exploring some of these issues."

Ryskina says these "nursing home specialists" have the potential to change the way health care is delivered in nursing homes if, for example, they help to improve patient outcomes and reduce costs in the nursing home setting.

"And that's the question that remains to be answered—whether this specialization we see in the data is correlated with an improvement in patient outcomes," she says. "Or on the other hand, will these clinicians, with their additional expertise, charge higher rates and increase costs but not really change outcomes?"

Another question that should be addressed in the context of these kinds of studies, according to Paul Katz, MD, a professor and chair of the department of geriatrics at the Florida State University College of Medicine, is whether a clinician can or should be labeled a "nursing home specialist" or "skilled nursing facility specialist" simply because he or she spends the vast majority of time practicing in a nursing home setting.

Katz has focused on the question of the nursing home as a practice site, having coauthored a 2009 article published in the Annals of Internal Medicine that examined existing problems in skilled nursing facilities. In that article, he and his coauthors proposed the creation of a nursing home specialty that would recognize the nursing home as a unique practice site. "Reviewing what is known about physician practice in nursing homes and hospitals, and taking a lead from the hospitalist movement," they wrote, "the specialty would be characterized in three dimensions: the degree of physicians' commitment, physicians' practice competencies, and the structure of the medical staff organization in which they practice."

They further pointed out that physician care can influence nursing home residents' hospitalization rates and functional status, and that marginalizing physicians within nursing homes threatened the overall care of residents who have a wide variety of medically complex illnesses.

"It's somewhat gratifying that the evidence we've seen over the last few years is starting to lend credence to the hypothesis in that 2009 article," Katz says.

He mentions a study published in 2013 in the Journal of the American Geriatric Society in which Kuo et al examined the association between the proportion of provider clinical effort in nursing homes and avoidable hospitalization and costs among nursing home residents in Texas.

Based on Texas Medicare claims data, they found that residents with primary care providers who devoted less than 5% of their clinical effort to nursing home care were at a 52% higher risk of potentially avoidable hospitalizations than those patients whose primary care physicians devoted 85% or more of their clinical efforts to nursing homes.

What Warrants the Title?
"That was not a controlled experiment," Katz says. "But it starts to paint the picture that there are probably consequences to having a practitioner on site for a good part of the time. And that's what we were trying to explain in that Annals of Internal Medicine paper—that you need someone who is familiar with the staff, culture, and facilities and is there frequently enough to have a sense of how to provide optimal care. In that sense, the study by Kuo is important, and I'm guessing the investigators in those two JAMA articles are going to be looking at similar types of data."

However, Katz emphasizes that simply practicing in a nursing home setting is not enough to be labeled a specialist. In a letter to the editor of JAMA Internal Medicine in response to the study by Teno, Katz, along with two colleagues, wrote that providing care to nursing home residents "is necessary but not sufficient to be deemed a specialist in postacute and long term care."

"We want to get away from the notion that anyone can just go into a nursing home and practice," Katz says. "You really do need to have a skill set."

In that letter to the editor, Katz and his colleagues point out that the Society for Post-Acute and Long-term Care Medicine has defined 26 core competencies for attending physicians in nursing homes and additionally developed a corresponding online curriculum.

These competencies—described in a 2014 article in the Annals of Long-Term Care—are divided into the following general domains:

• foundation, which focuses on ethics, professionalism, and communications;

• medical care and delivery process;

• systems;

• medical knowledge; and

• personal quality assurance and performance improvement.

These domains acknowledge the following three major principles:

• The practice of postacute and long term care medicine requires a knowledge base and skill set that can be defined within a specific set of competencies and which reflect expertise found in a number of other specialties, including family medicine, internal medicine, hospital medicine, palliative care, rehabilitation, geriatric medicine, and psychiatry.

• While none of these discipline-specific competencies is individually sufficient to describe the full range of postacute and LTC medicine competencies, each one is necessary for effective practice.

• Competencies must reflect a mix of the many skills unique to each of these disciplines, which must then be operationalized within a unique care setting with its unique regulatory requirements while incorporating the full skill set of the entire interdisciplinary team.

"These competencies are the basic framework for the skills clinicians need to have to be competent practitioners," Katz says. He adds that there has been some discussion within the field of nursing home care about creating an actual specialty akin to that of hospitalist. "I think we can make the case like hospitalists, who have a skill set and knowledge base, and who make a difference in terms of quality," he says. "But that will require a much more concerted robust effort."

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.