Image of Marilyn Rantz, Ph.D., RN, FAAN

Medicare should scrap billing restrictions for direct care services provided by advanced practice nurses in nursing homes, say researchers from the University of Missouri’s Sinclair School of Nursing, citing results of a long-term study.

Investigators followed a six-year quality improvement program that put full-time advanced practice nurses in 16 Missouri nursing homes. The program allowed staff to preempt hospital transfers by providing preventive care onsite, resulting in better health outcomes for residents and $31 million in savings over the study period, the researchers reported.

The nurses received guidance from a multidisciplinary team and were able to assist in quickly identifying when residents risked a decline in health status. They provided early, evidence-based interventions such as IV fluids or antibiotics for conditions such as dehydration, urinary tract infections and pneumonia. Doing so helped avert problems before residents required a hospital transfer or emergency department visit, said study lead Marilyn Rantz, Ph.D., RN, FAAN.

Tackling dehydration, for example, was crucial. The common problem can quickly spiral into an emergency. 

“We put care systems in place to allow residents to receive additional fluids several times a day,” Rantz said. “Having the APRNs teach the nursing home staff about what types of things to be alert for helped identify small issues and early signs of illness before they became bigger issues that required an avoidable hospitalization.”

The nurses were able to sustain improved quality of care successfully in a majority of the facilities over the study period. Facility leadership stability and engagement in the project likely contributed to the outcomes, the authors wrote.

Rantz, a professor emeritus, said she has dedicated her career to improving the lives of people in nursing homes while helping them avoid traumatic hospital transfers, a problem she said her own mother experienced.

“If we can intervene and manage these residents in nursing homes where they are already familiar with the staff and the routine, that is the best place for them to be,” she said. 

But Medicare currently restricts APRNs hired by nursing homes from billing Medicare for direct care services, she and her colleagues wrote. “This unnecessary restriction of practice discourages nursing homes from hiring APRNs and should be abolished,” they concluded.

The full-time nurse program cost $35 million, and was funded by the Centers for Medicare & Medicaid Services.  

The study, “Missouri Quality Initiative in sustaining changes in nursing home care: Six-year trends of reducing hospitalizations of nursing home residents,” was published in The Journal of Nutrition, Health & Aging.