NPs 'Filling the Gap' in New York
STATEN ISLAND, N.Y. -- Puzzled, Gina Nelson, DNP, stood in her 90-year-old patient's kitchen and studied bottles of medication, searching for an explanation for why this typically active woman was lethargic and confused.
"Show me how you administer the meds," she instructed the patient's aide, who unscrewed the cap and poured a dose of the patient's seizure medication, phenobarbital in liquid suspension, without shaking the bottle first.
The aide wasn't mixing it correctly, Nelson recounts several months later, as she walks into the patient's home for a routine checkup. The patient, now lucid, greets Nelson with a smile.
Nelson is the founder and CEO of Primary Care Nurse Practitioners of New York (PCNPNY), a 24-hour, urgent care, house call service, run out of a single exam room clinic sandwiched between a gym and a commemorative crystal gift shop across from the New Dorp subway stop here. PCNPNY dispatches a retinue of roughly 40 NPs throughout New York's five boroughs.
"A house call is very different than an office visit. We can assess so much more," she says -- like the state of medication compliance.
Between house calls, Nelson argues with case managers, secures insurance coverage for things like shots of Lasix and nebulizer treatments, and negotiates with mobile medical testing companies to send x-ray, EKG, echocardiogram, phlebotomy, and other medical services to patient homes.
"If there's a problem, or a situation, we fix it," Nelson says. "We find a way. We're nurses."
Filling the Gap
On her right hand, Nelson wears two gold rings: one emblazoned "Gina" that her husband gave her 20 years ago, and an insignia ring from Sigma Theta Tau, the nursing honors society. "I take it seriously," she says as she makes a fist and points to the gold symbol of her profession.
"I started as a nurse more than 20 years ago. I loved being a nurse," Nelson says. She then worked her way from an associate degree through each subsequent level of education, including a dual degree in nursing and clinical nurse specialist, then earning her doctorate at Stony Brook University 3 years ago.
During her years as a critical care nurse, Nelson witnessed home-bound patients, who were brought via ambulance, undergo intense and invasive measures for basic or routine health issues.
In 2007, she opened PCNPNY on her own and started making house calls throughout Staten Island to treat patients who had difficulty accessing regular primary care, such as the elderly and patients with disabilities. This method of healthcare delivery worked well, but as the sole resource for in-home urgent care, when she took time off, many of her patients would wind up in the hospital.
In 2008, Nelson invited a friend, Theodora Cross, NP, to join her practice and eliminate gaps in care coordination. "We both had the same mind set: to keep the patients with the option of not having to go to the [ED], if they could be seen in the home," she says.
After a while, the duo attracted the attention of the case managers in the community. "The patients would argue with them [the case managers], not wanting to go to the hospital. In fact, refusing," Nelson says with a laugh.
From there, they started getting referrals, and Nelson had to start hiring more clinicians to manage growth.
"I started the practice on personal loans and credit cards totaling about $50,000. I would pay some back and re-borrow as needed," Nelson said. "I got out of the red after about 3 years, but we continue to teeter in and out of the red."
The Alternative Option
When they first raised their awning, a large blue and white shade displaying the name of the practice and its contact information, physicians in the neighborhood were apprehensive about the new clinicians on the block, Nelson says.
"I'm an old-fashioned doc, so when NPs came along, I wasn't too happy about it. I was very skeptical" says Staten Island primary care physician Edward Celmer, MD. "They're eroding our territory."
"We're not here to take your patients, we're here to help you," Nelson remembers what she told the doctors when they opened.
Nelson says the physicians eventually recognized the collaborative advantage of an NP house call. "[And now] we get referrals from physicians in the community," she says. "We act as an intermediary for them."
"They [NPs] go around to the houses of patients who can't get to the office, and that's very good," Celmer's voice softens as he thinks of Nelson. "And Gina ... she's top notch."
Celmer came to realize the value of PCNPNY, and now he's one of their two collaborative physicians.
Often, Nelson says, their referrals are to assess unwell, home-bound patients with chronic health conditions who haven't seen a clinician in 6 months or even a year.
But, she also admits, many primary care physicians have closed their doors for financial reasons. "Most of the docs that are left in my area are specialists," she says.
With only one small exam room in the clinic, PCNPNY isn't exactly a competitor with typical primary care physician offices. "Twenty-four hour urgent calls are what sets us apart," Nelson says. "Our house calls are not just routine."
Nelson refers to PCNPNY as "the alternative option." Alternative to the emergency department, that is.
House Calls
Nelson walks into her patient's living room and begins the examination by cracking a joke. The patient's response tells her whether the patient is lucid, Nelson says.
Nelson lifts back the covers, and begins to exam the woman's body, then slides a thermometer across the patient's brow, and slips a blood pressure cuff up the woman's frail arm. Nelson enlists the aide to help lift the woman into a seated position. "Lemme hear your lungs," Nelson, says, moving the diaphragm of her stethoscope around the woman's back.
Nelson said she finds reasons for the aide to physically interact with the patient, to see if the patient flinches or betrays signs of abuse or neglect. Every few months, Nelson says, she notices something is off between the patient and the aide, and investigates further.
In conversation with the aide, Nelson learns that the patient's Hoyer lift is broken, and there's been some trouble with swallowing water. "I'll call the company," Nelson says of the lift-maker, and then she instructs the patient's daughter to buy Thick-it to help her drink more smoothly.
"If we don't do this, her aide would be calling 911," Nelson says after the visit. "She'd come back with bed sores, sicker, weaker, on 10 meds," Nelson says. "I couldn't let that happen."
More than 95% of the time, Nelson says, her geriatric patients and patients with disabilities don't need to go to the hospital. And, she emphasizes, a trip to the hospital can be a tremendous burden on her patients. "Having to go to the hospital is a big stressor, especially if they go by ambulance," Nelson says.
In a 2013 NIH-funded study, Hsia, et al. reported that among 10 different outpatient conditions, the median charge for a visit to an ED in the U.S. was $1,233. That did not include ambulance fees.
"NPs are paid about 20% less than physicians for doing the exact same work," Nelson says.
And, when a patient who hasn't been seen by a primary clinician in several months calls for medication refills, a member of Nelson's team can go into the home and make sure that the medication is still appropriate and communicate with the primary clinician to determine whether any changes are necessary.
This way, Nelson says, "somebody had eyes on them."
PCNPNY Operations
PCNPNY services the five boroughs of New York City, Nassau County, and parts of Westchester. They have a 24-hour hotline where the acuity of a patient's condition can be triaged for same-day dispatches, if necessary, based on severity. And beyond access to the hotline, patients receive their regular clinician's cell phone number. "So they have that emotional security," Nelson says. "That's very important."
To provide good continuity of care, "We always try to send the same nurse practitioner who has been managing that patient," Nelson says. "That's so important." However, if the regular clinician is off-duty or out of town, the electronic medical record with remote cloud server allows the NPs to access charts, take notes, and code remotely.
Among the 40 NPs in the PCNPNY network, Nelson has both full-time and per diem clinicians in primary care, and a diverse mix of specialties: gastroenterology, psychology, women's health, diabetes, patient education, and men's health. Nelson also estimates that nearly one-quarter of her clinicians teach at nursing schools in and around New York. "Everybody has a different, unique situation," she says.
One of Nelson's four daughters, Tonya, who is an RN, manages the PCNPNY office, triages patient calls, facilitates dispatches, and reviews charts. The next eldest daughter is the practice manager. Nelson even has a brother who does what he can for the community. The local legend, Ink Man, makes sandwiches to pass out to the homeless on the subway.
Jerry Varrone, NP, a member of the PCNPNY team, stops by the clinic. His background is also in critical care. "[House calls are the] wave of the future for NPs. Almost all treatments can be done in the home. [The patients] get better, and there's no secondary disease from the hospital," Varrone says.
"And some of them are frightened," Nelson adds. "That's where we can reduce that stress, [and patients often say] you're the only one who got back to me."
The Business End of the Stethoscope
To start a practice model like PCNPNY, Nelson says time is more precious than money. "Credentialing is a long and tedious task that can take up to a year, [and] without this you cannot get paid," she says. "If you can't get paid, you can't make it."
Overhead and expenses include legal and company structure set-up fees, rent, utilities, medical equipment, supplies, vehicle, gas, tolls, office staff payroll, payroll taxes, state and federal taxes, clinic site and malpractice insurance, and fees for bookkeeping, a billing service, workers compensation, state insurance, disability insurance, professional licensing and continuing education units (CEUs).
And for now, collaborating physician fees. However, in January 2015, physician oversight will no longer be required for NPs in the state of New York.
Securing licensure and legalities on the physical site and credentialing with the insurers "[are] the biggest first leg," Nelson says, adding that "patient base will build itself once you start providing the best service possible."
And if word isn't getting out fast enough, Nelson recommends calling community social workers, skilled nursing facilities, and hospitals to let them know you're doing a home visit practice, and that you would like to follow the patient home to help them remain stable. "That's quite important, especially with hospitals being penalized for readmissions within a 30-day time frame."
"These are partnerships," Nelson says. "You have to go out and build them."
Beginning in 2015, New York will be one of 15 states experimenting with Fully-Integrated Dual Advantage (FIDA), a pilot program for dual-eligible Medicare/Medicaid patients, and Nelson just closed a deal to treat FIDA patients.
Under the terms of the contract, PCNPNY will be responsible for all care for these patients "from A to Z." FIDA-qualified patients will be able to choose PCNPNY without a copay.
The practice takes all types of insurance. If an insurance provider isn't working with PCNPNY in terms of a home visit, Nelson says, "I'll reach out to them and try to show them how important this service is."
"I almost want to tell you they could pay with a goat," she laughs, "but that's how we feel about it. We don't turn anyone away."
The Future
"I think [PCNPNY is] going to evolve," Nelson says. She has a long list of clinicians waiting to come on staff. And she's looking forward to being able to bring specialty consultations like cardiologists into patients' homes via laptop or tablet interface.
PCNPNY's model of care should be duplicated all over the country, Nelson says as she puts her black bag of medical equipment in the back of her Buick SUV, preparing for another house call. "It's a much needed service."