The Impact of Nurse Practitioners on Hospitalizations and Discharges from Long-term Nursing Facilities: A Systematic Review

The objective of this study was to increase the understanding of the role a nurse practitioner (NP) has in reducing the risk of hospitalizations and improving quality outcomes among nursing facility residents. This was explored by the research team conducting a systematic literature review via Cumulative Index of Nursing and Allied Health Literature, PubMed (MEDLINE), and Academic Search Ultimate. This is of concern because of the increased rate of hospital readmissions from skilled nursing facilities. The study found that utilization of NPs as primary care providers resulted in decreased unnecessary hospitalizations, increased access to healthcare, and improved health outcomes. NPs are fundamental in building relationships with residents and families and providing them information for decision making. The utilization of NPs in a long-term care setting should be encouraged to improve access to care, decrease hospitalizations, and enhance quality of care. States with reduced or restrictive scope of practice for NPs should revisit the regulations to provide unrestricted scope of practice for NPs.


Introduction
Nurse Practitioners (NPs) are trained to provide primary care in multiple settings including adult, family, pediatric heath, women's health, and gerontology. NPs play a variety of roles in the long-term care setting to include providing both acute and primary care to short-term and long-term care residents, staff consultation on patient issues, and education to residents, families, and staff [1]. Primary services provided by NPs have been found to provide equivalent or more effective chronic disease management in treatment of hypertension, diabetes, depression, and congestive heart failure, than physicians [1,2]. Improved outcomes were noted in functional status of residents with NPs as primary care providers [1]. Nursing facilities with NPs were found to have lower hospitalization rates for diagnoses such as congestive heart failure, chronic obstructive pulmonary disease, hypertension, asthma, and diabetes [1,3,4]. The odds of ambulatory care sensitive hospitalization were 43% lower and 50% lower in Alzheimer's disease or dementia-related diagnoses in facilities with an onsite NP [1,4,5]. Decreased hospitalization results in reducing the cost of care [1,4]. NPs provided a timelier response, spent more time with residents, and conducted more comprehensive assessments than physicians [1]. Onsite NPs improved staff morale, resident satisfaction, and family satisfaction [1,4,5].

Background
Nursing homes are a vital element of the long-term care system. They play an important role in caring for the most sick, frail, and vulnerable elderly adults. The United States Census Bureau has projected that by 2050, the number of Americans aged 85 years and older will be approximately 19 million [2]. Nursing facilities provide services to meet the medical and psychosocial needs of residents. They also are expected to provide high standards for quality of care and quality of life. Quality of care and quality of life include effectively managing transitional care. Transitional care is coordinating continuity of care to other healthcare facilities or back to the community [3]. The transfer of a resident to a hospital is an example of transitional care.
Nursing home residents are at higher risk for hospitalizations [3,4]. One-fifth of all Medicare beneficiaries were reported to be readmitted to the hospital within 30 days of discharge [3]. It is estimated that 90% of these hospitalizations were unplanned and cost Medicare approximately $17.4 billion [4]. Many of the rehospitalizations were considered to be preventable such as rehospitalizations secondary to congestive heart failure (CHF), respiratory infections, urinary tract infections (UTI), sepsis, and electrolyte imbalance [4,5]. Hospitalizations due to the five aforementioned conditions accounted for 78% of potentially avoidable thirty-day skilled nursing facility rehospitalizations [4]. It is estimated that potentially avoidable rehospitalizations from a skilled nursing facility cost Medicare $3.39 billion in 2004 [4]. It is reported that one in six nursing home residents have a hospital admission within any given six-month period [5]. Approximately 40% of the long-term care residents have a hospital transfer within 30 days prior to their deaths [5]. Some of the causes of preventable hospital readmissions include inadequate management of chronic conditions, inadequate management of infections, and other unplanned events [1,4].

Significance
The diagnostic-related group (DRGs) payment system in hospitals has resulted in shorter hospital length of stays [1,3,4]. It has resulted in hospitals discharging patients "quicker and sicker" to nursing facilities [1]. The increase in the number of nursing home residents with clinically complex needs poses a challenge for facilities and physicians to meet them [1,4]. The addition of NPs to the clinical staff can help meet resident needs, provide quality of care, and reduce hospitalizations [1].
The main objective of this literature review is to investigate the role of an NP in reducing hospitalizations and improving quality outcomes in long-term care settings. The study will identify both areas for successes and barriers with the role of the NP.

Design
This study used a systematic review of peer-reviewed articles found in three research databases, Academic Search Ultimate (ASU), CINAHL Complete, and PubMed. The benchmark of acceptability for the topic and Boolean search was no less than 30 unduplicated articles from the three research databases. Using a 4-string Boolean phrase, each author searched for articles pertaining to the research question. This study used terms outside normal MeSH terms, as we were able to realize a much richer base of articles when we utilized different terms for our Boolean search. The initial search was conducted on 22 September 2019. Upon reviewing the articles found during the initial search, the authors used cited articles from the reference lists which led to additional articles meeting the inclusion criteria. The final articles were found on 19 October 2019, completing the search for data needed for the systematic review. The Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines were used to ensure consistent and precise reporting of search results. This review was also constructed and conceptualized using the Kruse Protocol for writing systematic reviews [6].

Inclusion Criteria
All authors individually reviewed the articles from the searches. Articles were eligible for inclusion if they were published by academic journals or universities between 1 January 2004 and 30 August 2019. The articles had to be published in the English language and pertaining to humans only. Articles had to explore nurse practitioners impacting hospital admissions or readmissions for patients in long-term care to be included in the systematic review.

Exclusion Criteria
Articles were only incorporated if deemed germane by all authors. Articles that were systematic reviews, literature reviews, or metanalyses were excluded. Articles that pertained to nurse practitioners in acute care were not included. Analysis of projected proposed use of nurse practitioners or conceptual models were excluded. The review did not include comparisons of physicians to nurse practitioners in relation to hospital readmissions. Bias was not considered when reviewing the research involved in this study. The final sample of articles after meeting exclusion criteria was then analyzed further for consensus among all authors for final inclusion. When analyzed, the sample yielded a kappa statistic (k = 1), showing strong reliability.

Study Selection
The article selection process is outlined in the PRISMA flow diagram in Figure 1. The initial search protocol identified a total of 65 articles from the three databases. Eleven articles were excluded when articles were filtered to include English and humans only, published between 1 January 2004 and 31 December 2019. Researchers chose to extend the search parameters to fifteen years due to a lack of relevant research in the field. Forty-two articles remained and 28 duplicates articles were removed leaving a total of 14 articles. Upon reviewing the articles found during the initial search, the authors used cited articles from the references lists which led to additional 16 germane articles. The total number of articles for the systematic review was 30. Articles had to explore nurse practitioners impacting hospital admissions or readmissions for patients in long-term care to be included in the systematic review.

Exclusion Criteria
Articles were only incorporated if deemed germane by all authors. Articles that were systematic reviews, literature reviews, or metanalyses were excluded. Articles that pertained to nurse practitioners in acute care were not included. Analysis of projected proposed use of nurse practitioners or conceptual models were excluded. The review did not include comparisons of physicians to nurse practitioners in relation to hospital readmissions. Bias was not considered when reviewing the research involved in this study. The final sample of articles after meeting exclusion criteria was then analyzed further for consensus among all authors for final inclusion. When analyzed, the sample yielded a kappa statistic (k = 1), showing strong reliability.

Study Selection
The article selection process is outlined in the PRISMA flow diagram in Figure 1. The initial search protocol identified a total of 65 articles from the three databases. Eleven articles were excluded when articles were filtered to include English and humans only, published between 1 January 2004 and 31 December 2019. Researchers chose to extend the search parameters to fifteen years due to a lack of relevant research in the field. Forty-two articles remained and 28 duplicates articles were removed leaving a total of 14 articles. Upon reviewing the articles found during the initial search, the authors used cited articles from the references lists which led to additional 16 germane articles. The total number of articles for the systematic review was 30.

Assessment Tools
The 30 articles selected for the systematic review were summarized to include the author, aim, setting, methods, assessment tool, and key findings. The summary of articles is listed in Table 1. The authors examined and analyzed the 30 selected articles, identified facilitator and barrier themes, and then sorted the articles according to their respective facilitator or barrier theme. Using the Affinity Matrix, facilitator and barrier themes associated with NPs reducing hospitalizations and improving quality outcomes in long-term care settings were listed by frequency of occurrences using articles numbers. The sum and percentages of the frequencies of facilitator and barrier themes were then calculated. The Affinity Matrix diagram is demonstrated in Table 2.

Results
A total of 30 articles published over a fifteen-year period, 2004 through 2019, were reviewed. All the articles reviewed discussed the impact nurse practitioners had in reducing hospitalizations and improving quality outcomes in the long-term care setting. Themes were identified and sorted into positive facilitators and negative barriers impacting nurse practitioners and patient care with regard to hospital admissions or readmission to hospitals for residents of long-term care facilities. Nineteen themes were identified, ten of which were facilitators, nine of which were barriers.
Improved health outcomes were associated with NP interventions and care, as indicated in 19.85% of occurrences [7][8][9][12][13][14][16][17][18][19][20][21]23,24,[27][28][29][30]32]. NPs, as primary care providers, advocated for patients and families, improved chronic disease management and care planning, and reduced depressive symptoms in patients they treated [20,24,29]. Time NPs spent in nursing activities were highly correlated with improved health outcomes, as well [9,24,28]. For example, when NPs provided only two hours on average per month for six months, elders in their care were able to improve function with a hip fracture and increase their activities of daily living [24]. Patients transferring between inpatient hospitals and nursing facilities had improved outcomes when a full-time NP was on staff [28]. Additionally, patients seen by NPs within four days of admission to a long-term care facility had lower mortality and costs during the following month [9]. Once residents and their families experienced NP care, patient satisfaction and family and patient requests for NP services improved [19,32].
Improved quality of care was mentioned in 23 of 132 occurrences (19.21%) of facilitator themes encompassing the improvement of quality measures, providing education to staff and assisting with clinical care, and involvement with quality improvement initiatives, e.g., the Intervention to Reduce Acute Care Transfers (INTERACT) [7][8][9][12][13][14][16][17][18][19][20][21]23,24,[27][28][29][30]32,33]. One qualitative study reviewed provided insights to person-centered care from the residents' and family perspectives [23]. Relationships between the patients, families, and the NP were fundamental to the experience of life within the community of a long-term care home [23]. Not only was the quality of care improved by having the NPs work in these settings, but also both residents and family members expressed how they valued NP's sharing information with them and involving them in decision-making related to care [23].
When NPs were utilized, patients experienced increased access to healthcare, patient and family education, and a multidisciplinary approach [13,18,20,21,[23][24][25]29,30,32,33]. Increased access to healthcare was mentioned in 14 of 132 occurrences (10.29%) of facilitator themes [18,20,[23][24][25]30,[32][33][34]. Failures in the traditional process of primary care provider referrals negatively impacted quality outcomes of resident care [32]. When utilized, NP services adequately filled the gap [32]. In fact, in long-term care, NPs often played the lead role as primary care providers [34]. Their ability to communicate and collaborate with other healthcare professionals, patients, and their families about their chronic illnesses, disease trajectories, and their goals of care positively impacted clinical outcomes [20,21]. Additionally, NPs provided staff education to address underlying causes of falls and other medical conditions such as dehydration, muscle weakness, and medication side effects further improving clinical outcomes [13].
The theme of reduced healthcare costs was mentioned in 9 of 132 factors of facilitation (6.62%). NPs reduced healthcare costs, lowering Medicare expenditures per patient by reducing emergency room visits and providing cost-effective care [7][8][9]11,12,14,23,30]. One study reviewed indicated that when integrating NPs to care, patient savings of $13,000 were seen when hospital charges were compared between the cohorts [7]. Additionally, NPs increased revenue by keeping the patients within the long-term care setting for treatment [8].
The theme NPs working in an unrestrictive or least restrictive scope of practice occurred in 10 of 136 occurrences (7.35%). Those NPs working at this capacity were well positioned to promote high quality care, multidisciplinary collaboration, communication, education, leadership, advocacy, research, and evidence-informed practice [10,14,16,17,31,33,34,36]. Unrestricted scope of practice for NPs improved health outcomes and reduced the costs [34]. To ensure successful NP practice, both state and organizational policies should be taken into consideration [36].
NPs positively impacted end-of-life care for residents in nursing home facilities [16]. Themes of improving end-of-life care were mentioned in 2.21% of the occurrences. With the advent of NPs with palliative care expertise, end-of-life nursing home care was improved by reducing acute care use and potentially burdensome care transitions for residents with advanced illness [16].

Barriers
Nine barrier themes were identified. Their occurrence, frequency sum, and percent frequency are shown in Table 2. The negative barrier theme most often mentioned was the restrictive scope of practice for NPs, identified in 13 of 45 occurrences (28.89%) reviewed [9,14,16,20,23,24,31,32,[34][35][36]. Lack of policy and funding, Medicare regulations, state regulatory constraints, prohibited billing for visits, and no authority to write or change orders were all contributors to restrictive scope of practice for NPs [9,23,24,32,34,35]. These restrictions required direct or indirect supervision from physicians for NPs, as well [31]. Changes in Medicare regulations are needed to facilitate improved utilization of NP services in long term care facilities [14].
Poor quality of care was identified as another barrier in 11 of 45 occurrences (24.44%) [13,19,20,22,27,28]. In some cases, the use of NPs as primary providers caused delays in care of the resident and outcomes, however, these outcomes were not significant when compared to physician outcomes [28]. Poor discharge protocols from hospitals to nursing facilities caused issues with rehospitalization before residents could be seen by NPs [13,28]. Further issues with discharge and admission to nursing facilities caused approximately 27.9% of residents to not be seen by physicians or NPs before hospital readmission [28]. This contributed to increased mortality rates of residents due to slowed time from admission to treatment by NPs [19]. Many facilities used objective tools at admission to assess acuity of residents and these tools were not used appropriately, thus increasing time to NP intervention [20]. There was also some evidence of increased mortality rates [19] and a lack of improvement of the care being given by NPs [27], however these were not more significant than care provided by physicians.
Lack of access to healthcare was identified as another barrier to the use of NPs in 7 of 45 occurrences (15.56%) [17,20,22,23,27,29]. Unfortunately, choices made by families or residents often resulted in discharges to hospital instead of care being provided by NPs [29]. Conversely, there was also a lack of available NPs in many areas to provide care to residents [17]. Both this lack of available staff and lack of specifically trained NPs in behavioral interventions resulted in a lack of proper behavioral health care being provided [17,20]. Nursing facility residents have a 25% greater chance at acquiring chronic conditions [22]. Of these chronic conditions, there are five that account for approximately 80% of hospital admissions/readmissions which are difficult for any provider to manage [22]. There is a perception that NPs are not aggressive enough in encouraging rehabilitation [27], however it should be noted that this is relatively dictated by resident payor status to begin with. When NPs were tasked with covering too many nursing facilities, this caused a decrease in the level of care [23].
Inadequate staffing was also identified as a concern surrounding the use of NPs in 6 of 45 occurrences (13.33%) [8,10,17,23,28,33]. Many long-term care facilities operated with limited resources and inadequate staffing further increasing the barriers NPs faced [8,10,17,23,28,33]. Many long-term care facilities do not have the capacity or resources to have an available NP to perform a stabilization and medication reconciliation visit upon each admission, for example [8]. Additionally, many transfers occurred on evening and night shifts which had lower staffing levels [17].
Patient and family preferences due to decreased patient satisfaction were also identified, occurring in 6.67% of the occurrences. Both were identified as barriers to NPs' impact to reduce hospitalizations and improve quality outcomes in the long-term care setting [17,23,29]. Residents may prefer to get treatment and/or insist to go to the hospital, for example, instead of receive care from the NP at the long-term care facility [17,23]. It is probable that in circumstances where acute illness or injury arise, the preference for the transfer of patients predominates even when alternatives exist [29].
Poor decision making [18*] (4.44%), increased hospitalizations [19] (2.22%), increased healthcare costs [19] (2.22%), and poor communication [36] (2.22%) were also identified as barriers. Poor practices by the discharging hospitals resulting in early rehospitalizations occurred many times before patients could be evaluated by an NP [19]. For those patients admitted to the long-term facility, many were transferred back to the hospital within 30 days of admission due to functional decline, suspected respiratory infections, and new urinary tract infections [18]. Hospitalizations from these conditions could have been potentially avoided should an NP have provided care and treatment [18]. For those communities utilizing NP services, NPs often covered a high number of residents over multiple homes negatively affecting the quality of care and increasing patient transfers to hospitals [36]. Management changes, i.e., administrators, directors of nursing, and other key personnel may also negatively impact the already existing deficiencies in NPs' perceptions of their relationship with administration and how their role is understood and valued in their organizations [18,19].

Discussion
The study findings indicate that NPs play an important role in improving health outcomes, quality of care, and reducing hospitalizations in a long-term care setting. The facilitators of NP roles outweigh the barriers in the long-term care setting. State quality initiatives show clear benefits of the use of full-time advanced practice registered nurses. These benefits are in quality improvement activities, increased end-of-life decision making, and improvements in the use of health information technology. Benefits of the use of systematic care tracking tools such as the use of the Interventions to Reduce Acute Care Transfers (INTERACT) were also noted. Avoidable hospitalizations actually increased under the use of NPs by 7% overall, however unavoidable hospitalizations decreased by an impressive 17%. The use of NPs has allowed a much more directed examination of care delivery systems, and measures to be put into place to correct any deficiencies in this area. The use of NPs to review medications and to reconcile them resulted in a 5.7% decrease in unnecessary hospitalizations.
Overall, the use of NPs reduces acute care usage, hospitalizations, and it eases care transitions when they do occur. NPs bring an increased ability to build relationships with families and residents, and to help both populations to better understand the care and to make well-informed choices. These are all significant areas which contribute to an increased quality of care which occurs when a NP is involved. There is a marked difference in health outcomes and hospitalizations in states with high levels of NP involvement as opposed to states with lower involvement. The utilization of NPs in a long-term care setting should be encouraged to improve access to care and to enhance quality of care.

Limitations
The authors identified limitations to this review. Our search strategy relied on a 4-string Boolean phrase and germane topics assigned by authors and may have missed instruments that are relevant to the role of an NP in reducing hospitalizations and improving quality outcomes in long-term care settings but were not identified. Many of the articles reviewed had small sample sizes which limited the generalizability of the individual study results. Additionally, because each long-term care facility had different dynamics, the results of this review may not be generalizable. Many long-term care facilities do not have the capacity or resources to have an available NP. Only English language articles were included in the review, so we did not capture the perspectives of people from different backgrounds.

Future Research
An unexpected finding during the systematic review was the restrictive state and federal regulations regarding NPs. Future research and review of the different restrictions could assist with enabling NPs to practice more freely, improving quality outcomes and decreasing hospitalizations. More research using larger samples in the area of NP impact on long-term care quality outcomes and decreasing hospitalizations would increase the generalizability of study results. Future studies should address NPs' impact on decreased hospitalizations and improved quality outcomes other than those in primarily English-speaking regions. Further areas of future research may also include the impact of NPs on staffing shortages surrounding physician providers. The inclusion of NPs could also significantly change the administration of medical care in nursing facilities. However, the role of the NP could also prove to be challenging as well when it comes to the provision of that care and the differences in states with full practice rights for NPs and those without.