Long Term Care

The pandemic has brutally exposed vulnerabilities in long-term care (LTC) homes but one solution is hiding in plain sight – Nurse Practitioners, or NPs.

Background

Most residents of today’s long-term care (LTC) homes are frail, have multiple chronic health conditions, and are in mid to advanced stages of dementia, all which lead to unpredictable and complex care requiring knowledgeable assessments and interventions by qualified health-care providers. 

COVID-19 has underlined the importance of having on-site clinicians available to provide expert assessments, care and timely follow-up as well as the ability to work collaboratively with staff to deliver the care that was planned. One solution hidden in plain sight are Nurse Practitioners, or NPs, who have a proven track record of improving the lives of residents in LTC homes and their families.

The majority of residents in LTC homes are attended to by family physicians who are often the Medical Director for that home. Some of these medical directors have competing demands from their primary care practices, emergency departments or their work in multiple LTC homes and thus have limited contact with the residents .

During the first wave of the pandemic, physicians were advised to assess residents virtually because of their multiple responsibilities across different sites. This, in turn, created challenges for staff attempting to access medical care for residents, especially on-site care. In response, the Ontario government issued an emergency order in March 2020 enabling NPs to work as medical directors in LTC homes and to act as the most responsible providers.

NPs are advanced practice nurses who began as Registered Nurses, have extensive experience and have graduate-level NP education that prepares them to comprehensively assess, diagnose, prescribe and treat residents living with chronic conditions and episodic acute challenges[DC1] .

In Ontario, there are two approaches to the deployment of NP’s to LTC homes: attending NPs and nurse-led outreach teams (NLOTs). Attending NPs are employed by LTC homes, where they provide on-site care to residents and work in a shared model with physicians. Working full-time in one or two homes, they manage the overall health care of residents. Alternatively, some NPs are part of NLOTs most often employed by hospitals to provide on-site care to as many as 10 or 20 LTC homes, with the main goal of dealing with acute and episodic issues to reduce emergency room visits.

During the pandemic, many NPs have been working in one LTC home full-time, usually in homes with the highest rates of COVID-19 providing on-site assessment and management. In this role, NPs have expanded their responsibilities to provide additional support to management, staff, residents and families. The majority of NPs now offer in-person care and educate staff on infection prevention and control and COVID-19 care. They provide oversight for staff regarding personal protective equipment and moral support to those anxious about contracting the virus. 

NPs are involved in keeping families informed of residents’ statuses, often daily, and updating them on their plans of care. In addition, NPs have developed new models of collaborative care in LTC homes, which have improved access to specialist and emergency care consultations, including virtual visits. 

NPs are also working to strengthen capacity within the LTC home by mentoring staff and facilitating the implementation of best practices related to care of older adults with COVID 19. Registered Nurses are in short supply in LTC homes and the NPs filled some of that resource. This includes discussing goals of care, minimizing adverse outcomes, reducing social isolation and ensuring dignified end-of-life care for residents.

Research shows that deploying NPs to LTC homes results in a decrease in unnecessary hospitalizations and an increase in access to health care while providing safe and cost-effective care, improved health outcomes and family satisfaction.  Additional research shows that NPs provide information to residents and families that facilitates better decision-making. 

Moving forward, NPs are a viable solution to address the LTC home crisis, during and beyond this pandemic. Ensuring that the right NP deployment approach – attending NPs versus nurse-led outreach teams– aligns with the needs of the local region will be imperative going forward. Future synergy of both approaches would enhance LTC homes’ capacity. An investment must be made to create dedicated funding to support the creation of more NP positions in LTC homes in Canada.

Position Statement

  1. Funding to Increase NP Leadership with LTCH ○ NPs should be able to hold the Medical Director position in LTCH.
    1. Adjust wording within the LTCA to include Nurse Practitioners in the mandatory roles for LTCH (i.e. Director of Nursing and Personal Care, Medical Director, Registered Nurse)
  2. Increase NP to Resident Ratio ○ At least 1 full-time NP for every 100 LTCH residents.
    1. For LTCH with 100 residents or more, 3 full time NPs should be employed to provide 24 hour coverage with an attending NP present.
    1. Increase involvement of NPs in LTC to at least 5% of the registered workforce (currently less than 1%)
  3. Address Increasing Complexity and Acuity of Residents with Full Time NPs
    1. Increased utilization of full time NPs as Directors of Care and Medical Directors
    1. Ensure the ongoing sustainability of the existing NLOT programs and provide for every LTC home in Ontario to have access to an NLOT team by doubling the numbers of teams from 14 to 28 within the province.
  4. Support NPAO in the development of a practical continuing education course that can lead to a Long Term Care Resident Care certification.

The Canadian Nurses Association (CNA) identifies the competencies of NPs as:

  1. Professional Role, Responsibility and Accountability
    1. Clinical Practice
    1. Collaboration, Consultation and Referral
    1. Research
    1. Leadership
  1. Health Assessment and Diagnosis
  2. Therapeutic Management 
  3. Health Promotion and Prevention of Illness and Injury

The parallels between the competencies and capabilities of NPs with the needs identified within LTC are obvious.  It’s time to leverage the expertise of Nurse Practitioners to improve the quality of patient care in LTCHs.

LINK:  NPAO RESPONSE TO LTC STAFFING STUDY

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