Health care reformers say closer medical cooperation will help eliminate the fragmentation that, according to the Commonwealth Fund and other entities, puts patients at risk; results in waste; hinders delivery of high-quality, efficient care; and rewards high-cost, intensive medical intervention over primary care, including preventive medicine and management of chronic illness.¹

Besides making things better for patients, the improvements involved in defragmentation, such as adopting electronic health records, coordinating care, avoiding medical errors, and determining and using the most effective and latest treatments, are expected to result in billions in savings that can be used to help finance health care reform. Peter R. Orszag, the White House budget director, believes adopting proven and successful practices could save $700 billion a year without compromising the quality of care.²

The concept of closer medical cooperation is at the heart of the patient-centered medical home in which a personal physician coordinates with other professionals all of a patient’s health care needs in all stages of life (eg, preventive services, acute care, chronic care, and end of life), across all elements of the health care system (eg, subspecialty care, hospitals, home health agencies, and nursing homes), and in the patient’s community (eg, family and public and private community-based services).³

Originally developed and proposed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Physicians, and the American Osteopathic Association and now supported by a coalition of more than 500 members, including the American Medical Directors Association, the medical home has just been endorsed by the American Medical Association.⁴

But making leaps from concept to the real world have often been difficult for health care reformers, and although there’s a growing consensus that changes, like these, to make health care more efficient can result in significant savings, “little reliable evidence exists about exactly how to implement those types of changes,” says Congressional Budget Office Director Douglas W. Elmendorf,⁵ who in June issued the infamous "scorings" that stalled Senate health care legislation because of unexpectedly high costs and failure to cover more people without health insurance. One thing is for sure, as spelled out in the patient-centered medical home proposal and others: implementing these quality-related changes will involve diverting some of the potential savings into incentives for medical professionals.

So, how have government-guided efforts to implement quality-related changes fared in LTC, specifically in forging closer cooperation among medical professionals? The results have been generally favorable, as discerned in the Senior Care Digest Interdisciplinary Report: A Survey of Long-Term Care Health Professionals, part of the sanofi aventis Managed Care Digest Series^®.⁶ Government mandates to improve medication management, to increase oversight of nursing home staff, and to foster collaboration do appear to be engendering better communications and closer working relationships in LTC, at least from the perspective of medical professionals. (ALSO SEE, Long-term care: How MDs fit in, and what they're thinking.)

For example, a revision of federal quality assessments to focus on all aspects of medication management rather than just specific categories of medications (Tag F329—Unnecessary Drugs) is bringing medical professionals practicing in nursing homes closer together, according to the Senior Care Digest 2008 survey results. Asked if the requirement’s effect has been to improve professional collaboration among pharmacists, directors of nursing, and prescribers, nearly half of medical director respondents (49%) agreed that it has, while a majority of parmacists (65%) and directors of nursing (59%) said collaboration has improved. Asked if communications had increased among them, 73% of medical director respondents said they saw an increase, as did 71% of pharmacists and directors of nursing, and 59% of nurse practitioners.

Another federal requirement, which includes more oversight of nursing home staff by medical directors (Tag F501), is creating less conflict than before between medical directors and attending physicians, according to survey results (11% in 2007 down to 5% in 2008), indicating that they are finding solutions to previous challenges.

"Things have changed with the advent of the F-Tag," said one of the medical directors surveyed. "The medical director now needs to collaborate with the facility’s leadership, staff, and other practitioners in the facility."

Probably the best example of the benefit of forced cooperation is the degree of collaboration between physicians and nurse practitioners in LTC. In all but 10 states, a nurse practitioner must either have a collaborative arrangement with a physician or be supervised by one. Collaborative arrangements are needed in order to bill Medicare.

According to the 2008 survey, a majority of LTC medical director respondents (62%) indicated that they are collaborating with nurse practitioners, and most (65%) say that they enjoy the experience. The nurse practitioners are even more positive, with 83% saying that they enjoy the collaboration. A majority of medical directors (59%) say the collaboration improves quality of care, and 67% of nurse practitioners agree. (See detailed results.)

Even in the most contentious area, LTC collaborative pharmacy practice, a government mandate brings a semblance of cooperation. As commentary accompanying the 2007 survey suggests, the collaborative practice activity that received the greatest support from all four disciplines was therapeutic switching or substitution. This support may be related to the impact of Medicare Part D, which has led to increased communications between the nursing facility and the prescriber to ensure that a medication ordered is covered by the resident's prescription drug program. (See details on impact of Medicare Part D.)

By suggesting therapeutic alternatives, pharmacists could reduce a great deal of the additional paperwork and telephone calls while ensuring that residents receive appropriate therapies. Such reductions could be facilitated with a written agreement between the pharmacist and the physician, in which the pharmacist would be permitted to substitute certain medications when a nonformulary drug is ordered by the physician.

Collaboration between physicians and nurse practitioners

A very small percentage of medical directors and nurse practitioners indicated dissatisfaction with the collaboration (6% of medical directors and 3% of nurse practitioners). While one-third of medical directors said that they would like to increase the frequency of this collaboration, only 12% of nurse practitioners agreed.

Both groups most frequently identified daily or weekly collaboration to discuss patient-related clinical issues. (See detailed results.)

Of medical directors and nurse practitioners who currently do not collaborate, approximately one-third expressed interest in such activities (40% of medical directors versus 36% of nurse practitioners). Noncollaborating nurse practitioners more frequently said they believe that entering into a collaborative agreement would increase their medico-legal exposure (43%), compared with 27% of medical directors. Nearly half (43%) of nurse practitioners indicated that this relationship would be educational, compared with 19% of medical directors who currently are not involved in collaborative practice.

The largest discrepancy in responses was between the 71% of noncollaborating nurse practitioners who believe that collaboration would increase the quality of care, compared with only one-fourth of medical directors who believe the same.

A commentary accompanying the survey results notes that collaborative practice is a joint and cooperative enterprise that integrates the individual perspectives and expertise of various team members. Successful collaborative activities call for collegiality, teamwork, open communication, recognition of others’ expertise, and a strong level of trust and respect.⁷

When collaboration is effective, the commentary continues, it enables the highest quality and most comprehensive care that best meets the needs of a particular population—in this case, long-term care facility residents. Potential advantages of collaboration include allowing physicians more time to see medically complicated patients, enabling nurse practitioners to spend more time with patients needing extensive counseling, improved patient and family satisfaction, and more cost-effective care delivery.

The commentary notes that while there clearly are advantages to collaboration, there are also barriers. These include lack of understanding of the nurse practitioner’s role by physicians, concerns that nurse practitioners have less medical training than physicians, and worries about increased medico-legal exposure. In reality, medico-legal risks actually may be diminished by effective collaboration, because it enables physicians to have on-site assessment and intervention by the nurse practitioners rather than rely solely on telephone reports and test results from facility nursing staff.⁷ Additionally, with the emphasis on cost-effectiveness in health care, the nurse practitioners-physician collaboration is a good way to make the most of limited time and reimbursements.

As of early 2008, 39 states require a written agreement for NPs to collaborate with physicians.⁸ Seventy-nine percent of nurse practitioners currently involved in collaborative practice reported having a written agreement. Even where it is not required, a written understanding is recommended. This document should describe the physician-nurse practitioner relationship, including frequency and methods of interaction; how the interaction will be documented; on-call responsibilities; and when patients should be referred to the physician.

Nurse practitioners and physicians can collaborate in a variety of models, ranging from the nurse practitioner being employed in a group practice with physicians and other health care professionals and caring for residents in dozens of facilities to a single nurse practitioner collaborating with one physician and seeing residents in one nursing facility.

Collaborative practice by pharmacists

The 2007 survey indicated that a large majority of medical directors (71%) disagreed that states should even allow for collaborative practice by pharmacists. Almost every pharmacist (98%) thought the opposite.

As to whether pharmacists should be allowed to approve switches to therapeutically equivalent drugs, 83% of pharmacists strongly agreed, as did 32% of directors of nursing and 21% of nurse practitioners. Only 19% of medical directors strongly agreed. (See detailed results.)

On the question of pharmacists being able to discontinue drug therapy, 69% of medical directors strongly disagreed and only 1% agreed. There was similar sentiment about pharmacists ordering laboratory tests.

As of the 2007 survey more than 40 states allowed prescribers (generally physicians and, in some states, nurse practitioners) to authorize pharmacists to engage voluntarily in specified activities, including adjusting and/or initiating drug therapy. Directors of nursing (94%), nurse practitioners (92%), and medical directors (90%) agreed that special licensing should be required if state regulations allow collaborative practice. However, only 68% of pharmacists expressed support for such a requirement.

A commentary accompanying the 2007 survey results noted that collaborative practice is not new to pharmacy practice. For example, the US Department of Veterans Affairs has long allowed pharmacists to order medications and laboratory tests in clinical areas, including anticoagulation clinics, lipid management, and medication management. Pharmacists in other practice settings, both institutional and noninstitutional, are involved in varying degrees of collaborative practice.

References

1. Shih A, Davis K, Schoenbaum S, et al. Organizing the US Health Care Delivery System for High Performance. New York: The Commonwealth Fund; 2008.
2. Orszag PR. Health Costs Are the Real Deficit Threat. The Wall Street Journal. May 15, 2009. Page A13.
3. The Patient Centered Primary Care Collaborative. Joint Principles of the Patient Centered Medical Home. February 2007. www.pcpcc.net/content/joint-principles-patient- centered-medical-home. Accessed June 23, 2009.
4. AMA works to reform Medicare physician payment [press release]. Chicago, IL: American Medical Association. June 17, 2009.
5. Elmendorf DW. [Letter to US Sens. Kent Conrad and Judd Gregg]. June 16, 2009.
6. Simonson W, ed. Senior Care Digest Interdisciplinary Report: A Survey of Long-Term Care Health Professionals. Managed Care Digest Series® 2007 and 2008. Bridgewater, NJ: sanofi-aventis; 2007 and 2008.
7. Resnick B, Bonner A. Collaboration: foundation for a successful practice. JAMDA. 2003;4:344-349.
8. Pearson LJ. A national overview of nurse practitioner legislation and health care issues. Am J Nurse Practitioners. 2008;12(2):9–80.