The physician assistant (PA) profession is rooted in primary care. Although increasing numbers of PAs are choosing specialty areas, 32% reported practicing in primary care (family and general medicine, internal medicine, and pediatrics) in the 2013 American Academy of Physician Assistants’ (AAPA’s) national census. Although most medical care is delivered in outpatient offices, ambulatory care centers, and acute care hospitals, there is a growing trend for care to take place in the patient’s home, fueled by a need to decrease costs and personal desire to stay in one’s own home. That home may be an individual domicile, congregate housing, an assisted living facility (ALF), an inpatient hospice, or a skilled nursing or other long-term care facility. With this growth in demand, more PAs are choosing to work in nonmedical settings. In 2013, 1.4% of PA census respondents indicated working primarily in residences, with 0.9% in long-term care, 0.3% in hospice, and 0.2% in patients’ homes. The focus of this chapter is care delivery in these nontraditional venues. (See Table 41.1 for information on various sites of care.)
|Type or Site||Description||Payer|
|Inpatient rehabilitation hospital||Provide at least 3 hr of therapy per day; must make progress to continue||Medicare, Medicaid, or private insurance|
|Skilled nursing facility (SNF) postacute hospital; needs therapy||PT, OT, or speech; must progress to continue||Medicare or private insurance|
|Long-term hospital||Handle complex care such as ventilator patients||Medicare or private insurance|
|Home health care||Nursing or therapy in the home; requires face-to-face encounters with a physician, NP, or PA||Medicare, Medicaid, or private insurance|
|Hospice||May be in the home, NH, ALF, or inpatient hospice; avoids hospitalization; usual prognosis <6 mo; concentrates on comfort||Medicare or other|
|Home care or personal care||ADL and IADL care in the home||Varies but usually self-pay or Medicaid|
|NH||Chronically ill patients who are not able to benefit from rehabilitation and need nursing care||Self-pay or private insurance; Medicaid|
|ALF||Institutional care; may serve small or large numbers; services vary widely, and little regulation exists; patients are usually less disabled than in NHs||Self-pay; few Medicaid|
|Day care||Provide limited services during day; some housed in ALFs||Self-pay; Medicaid|
The “silvering” of the developed world is a well-established reality. This demographic shift will result in an aging “tsunami” of need for all kinds of care: medical, psychological, social, and functional. The disorders of aging do not conform to traditional medical approaches, which strive to find a single cause (diagnosis) to account for multiple symptoms. They are syndromes and thus are multifactorial, requiring a holistic approach by an interdisciplinary team. PA programs have included geriatrics and geriatric syndromes in their curricula since the 1980s. With a generalist-training model, PAs are well prepared to assume a growing role in coordinating and directing care for older adults. In addition, PA education focuses on “hands-on” clinical skills, those most readily available and needed to provide services in nonmedical environments. It incorporates a large amount of instruction in chronic disease management, a hallmark of aging and functional disability. PA education emphasizes preservation of function and independence, both of which are core values of the geriatric and disabled populations.
Most of the health care of older adults and disabled younger individuals is financed by Medicare, administered by the Centers for Medicare & Medicaid Services. Since 1998, Medicare Part B has reimbursed PA employers in all settings at 85% of the physician-allowable rate if the services are medically necessary and would ordinarily be provided by a physician. The care must be provided by PAs working with physician supervision and must be within the scope of practice allowed by state law and regulations. Supervision may be via telecommunication and does not necessarily imply the physical presence of the physician unless it is required by state law. PAs may bill any evaluation and management code except the initial comprehensive evaluation of the skilled nursing home (Part A) patient.
Table 41.2 lists the components of Medicare. Further information on reimbursement is provided in the section on each site of care.
|Part A||Hospital, hospice||Aged, disabled||Yes|
|Home health medical equipment|
|Nursing home rehabilitation ∗|
|Part B||MD, PA visits||Must elect and pay premium||Yes|
|Includes house calls and nursing home visits||Yes|
|Part C||Medicare Advantage plans, HMOs||Must elect||Varies|
|Part D||Prescription drug benefit||Must elect||Varies|
Home Care: Informal Caregivers
The 43.5 million unpaid family caregivers are the largest source of long-term care in the United States. They may provide care on a full- or part-time basis and may live with their care recipient or separately, some even at long distances. Most are women (usually wives or adult daughters), but there is an increase in the number of men serving in this role. Whereas men are more likely to assume instrumental activities of daily living (IADLs) such as handling finances, women tend to perform the “hands-on” activities of daily living (ADLs; bathing, dressing, toileting, feeding, and mobility). Women are more likely to experience emotional distress, anxiety, and depression related to their caregiving role. The majority of caregivers are middle aged (35–64 years); however, many caregivers of older adults, especially spouses, are themselves elderly. Older caregivers tend to spend more hours providing care and are more likely to have their own health concerns.
Over the past decade, with increasing numbers of care recipients with complex medical conditions, caregivers have found their roles shifting to include tasks usually considered medical or nursing, such as care of intravenous lines, injections, wound and ostomy care, and even management of home dialysis and ventilators. Sadly, many feel ill-prepared to provide this care, with about 50% reporting little or no education regarding these procedures. This may account for some of the frequent hospitalizations that occur in this group of high-complexity, high-needs patients and represents an untapped opportunity to reduce costs and increase caregiver and recipient satisfaction by providing more educational support. A systematic review of interventions to prevent hospitalization of demented community-dwelling older adults in 2015 did not find significant reductions in hospitalizations in any of the studies they considered. However, the authors did note that the studies had many methodological concerns, and none addressed caregiver education or focused on medical interventions.
About one fifth of the white and black populations in the United States are providing care, with slightly lower numbers of Asian and Hispanic Americans doing so. African Americans report less stress than white caregivers, and Hispanics and Asians experience more depression. One in 10 caregivers has served in the armed forces, as have their care recipients. Nine percent self-identify as lesbian, gay, bisexual, or transgender. Many caregivers find great fulfillment in their roles, enjoying closer relationships with their care recipients and satisfaction from providing what they believe is the best care for their loved ones. Most caregivers are employed outside the home, which, although it adds to stress in the workplace, may actually prove beneficial as a social outlet and a means of increasing income. Caregivers with higher incomes report less stress than those of more limited means.
Caregivers pay a high price emotionally and physically for their roles. Depression is the most common psychological disorder and is especially prevalent in those caring for demented persons. Elevated stress is associated with an increased likelihood of harm to the recipient. Caregivers also suffer disproportionately from increased risk for cardiovascular disease, immune system dysfunction, and elevated blood pressure. Elderly spousal caregivers experiencing stress have a markedly higher mortality rate than their noncaregiving, age-matched peers.
The monetary value of informal caregiving is difficult to assess but has been estimated to far outweigh the combined cost of home health and nursing home care. Although some support services are available, many caregivers are unaware of their existence or how to access them. Use of support has been shown to reduce stress and depression and to delay institutionalization by as much as 1 year. As the economic contributions of informal caregivers have begun to be recognized, there has been a movement toward legislative and regulatory efforts to provide more support for individuals to remain at home. These include redirection of Medicaid dollars to informal caregivers rather than to institutions.
As primary care providers, PAs can impart an invaluable service to their caregiving patients by helping them to optimize their own health. A PA may be the only social and emotional outlet for an often-isolated caregiver. Recognizing and expressing appreciation of their efforts can be a positive incentive to continue in the role. Providing information on community support programs and assisting the family in locating respite may be important therapeutic interventions for both the care provider and recipient. (See the Resources for recommended websites for caregiver support materials.)