Opinion

One Solution to the Long-Term Care Crisis: Nurse Practitioners

The pandemic has brutally exposed vulnerabilities in long-term care (LTC) homes, but one solution is hiding in plain sight – nurse practitioners, or NPs.

The majority of residents of today’s LTC homes are frail, have multiple chronic health conditions, and are in mid to advanced stages of dementia, all of which lead to unpredictable and complex care that requires knowledgeable assessments and interventions by qualified health-care providers. And COVID-19 has underlined the importance of having on-site clinicians available to provide expert assessments, care and timely follow-up as well as the ability to work collaboratively with staff to deliver the care that was planned.

Enter NPs, who have a proven track record of improving the lives of residents in LTC homes and their families. NPs are advanced practice nurses who began as registered nurses, have extensive experience and have graduate-level NP education that prepares them to comprehensively assess, diagnose, prescribe and treat residents living with chronic conditions and episodic acute challenges. NPs have a wide scope of practice that is valuable to LTC homes.

Usually, most LTC home residents are attended to by family physicians who are often the medical director for that home. Some of these medical directors have competing demands from their primary care practices, emergency departments or their work in multiple LTC homes and thus have limited contact with the residents.

During the first wave of the pandemic, however, physicians were advised to assess residents virtually because of their multiple responsibilities across different sites. This, in turn, created challenges for staff attempting to access medical care for residents, especially on-site care. In response, the Ontario government issued an emergency order in March 2020 enabling NPs to work as medical directors in LTC homes and to act as the most responsible providers.

In Ontario, there are two approaches to the deployment of NPs to LTC homes: attending NPs and nurse-led outreach teams (NLOTs). Attending NPs are employed by LTC homes, where they provide on-site care to residents and work in a shared model with physicians. Working full-time in one or two homes, they manage the overall health care of residents. Alternatively, some NPs are part of NLOTs most often employed by hospitals to provide on-site care to as many as 10 or 20 LTC homes, with the main goal of dealing with acute and episodic issues to reduce emergency room visits.

Throughout the pandemic, many NPs have been working in one LTC home full-time, usually in homes with the highest rates of COVID-19, providing on-site assessment and management. In this role, NPs have expanded their responsibilities to provide additional support to management, staff, residents and families. The majority of NPs now offer in-person care and educate staff on infection prevention and control and COVID-19 care. They provide oversight for staff regarding personal protective equipment and moral support to those anxious about contracting the virus.

NPs are involved in keeping families informed of residents’ statuses, often daily, and updating them on their plans of care. In addition, NPs have developed new models of collaborative care in LTC homes, which have improved access to specialist and emergency care consultations, including virtual visits.

NPs are also working to strengthen capacity within the LTC home by mentoring staff and facilitating the implementation of best practices related to care of older adults with COVID-19. Registered nurses are in short supply in LTC homes and the NPs filled some of that scarcity. Their work has entailed discussing goals of care, minimizing adverse outcomes, medication management, reducing social isolation and ensuring dignified end-of-life care for residents.

Research shows that deploying NPs to LTC homes results in a decrease in unnecessary hospitalizations and an increase in access to health care while providing safe and cost-effective care, improved health outcomes and family satisfaction. Additional research shows that NPs provide information to residents and families that facilitates better decision-making.

Moving forward, NPs are a viable solution to address the LTC home crisis, during and beyond this pandemic. Ensuring that the right NP deployment approach – attending NPs versus nurse-led outreach teams – aligns with the needs of the local region will be imperative going forward. Future synergy of both approaches would enhance LTC homes’ capacity. An investment must be made to create dedicated funding to support the creation of more NP positions in LTC homes in Canada.

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10 Comments
  • Randy and Jan Filinski says:

    There is so much emotion in the replies around LTC that I want to focus on a patient view of NPs as an essential part of any team who deal with “older adults with complexity ” and this is really a strong endorsement of NPs in this role over many years.

    This includes GEM nurses in acute care working within the emergency departments, includes (as per the article) embedding NPs in LTC, embedding NPS within Primary Care teams in urgent care settings and having NPs leading team based clinics in communities and CHCs.

    Recently, as a stem cell recipient and an 8 week hospital stay, I witnessed this incredible team based approach headed by surgeons and specialists but supported daily by NPs who not only would see me, but took the time to call my partner daily with updates due to covid restrictions. I would be remiss not to mention the frontline nurses 24/7 who worked 12 hour shifts with clinical expertise and empathy and it was the combination of my specialists, my NPs and the frontline that got me through….team based and each with an incredibly coordinated empathetic role. If you were to ask my partner about this, she would acknowledge the role of our NPs as so essential.
    Around the Province, I see NPs as essential as we build out OHTs, and where this is recognized, they will be more successful not because the are NPs, but because the offer a skill set that complements team based care and population focus.

    Maybe it is time for NPs to use the patient voice to help in future design and curriculums….we are supportive.

  • Florentina Rita TAMAS says:

    I agree that NPs deployed to LTCHs during pandemic helped to de escalate the crisis and strengthen capacity within LTCHs.

  • Hallie Bass says:

    I am a retired NP. I am in full support for NPs in LTC as well as primary care and wherever there is a need. Would the long term care situation been able to deteriorate to such an extent with more NPs? I was totally shocked to hear about some of the issues in LTC. Our community has a lovely newish nursing home. The staff look after them well and they are treated like family. Covid has created issues of isolation and loneliness, but the staff does their best. My practice patients miss me since my retirement. It has taken longer to replace me than anticipated and I have had to go back to do women’s health. My doc colleagues won’t divvy up my patients until my replacement is ready. And they don’t do vaginas or see anybody for anything but an emergency. They will call in prescriptions. I had 900 patients which was 40% of the population in my community and even if they split my crowd, they would still only have 750 each. And they are pissing and moaning about overwork! So…..
    NPs can do it and do it well. I am sick and tired about hearing that we can’t deliver as good as docs. I like my colleagues, but who picked up their slack, did all their women’s health and was the go to person. We can handle a lot of acute and chronic health needs and refer if we need to. LTC is an opportunity for NPs. Get with the program, Canada!

  • Theresa Robinson says:

    First and foremost..are they aware of the shape these LTCHOMES as many needed a Indoor face lift as we were Promised from Premier Ford.Being locked up for 4 months 4 to a Room and eating all meals in their Rooms..which caused bed bugs and Cockroaches. I think that many Death’s were caused by Not having one Activity for these Dear Innocent Residents and no fresh air or able to go for brief walks to Help there leg Muscle..without this you loose any Muscles you had. Also they Truly need Stimulation for their minds.With that said I mean I could go on..But what your offering I Agree to a certain extent. All these years these Residents have been Subjected to Unnessassery Cruelty..
    Also for the price you pay a Month and your served a Hot dog that is raw and no bun just a few Potato chips..Where’s the Justice!!!! Many require certain foods..That’ll be the day the cook is going make up certain dishes. I’ve now learned not to ever Purchase anything..As most of the time they never received it. Or 650$ in there own little savings if the day ever came that they were taken to a Store..But many have had there little bit of money Stolen..
    People are treated much better in Jails!!! I’m Sorry I can’t go on anymore about this..
    Thank you Kindly.
    Theresa Robinson. .

    • Dee Dee says:

      Theresa I don’t know what LTC homes you have been in however I have been a staff in LTC specifically the same home for the last 6 years and do I agree alot of these places need upgrades yes, do I agree that residents need more physical space to move and to be able to go for walks sure however where is the staffing going to come from to take residents out for walks especially residents who are prone to wondering from dementia when we are short of staff for even just basic care? And hot dogs, really? That statement is just rediculous. Our residents are not even fed hot dogs let alone a uncooked one, the menus are actually dietitian guidelined and if residents have special requirements such as diabetic diet, low sodium, or even specific textured they are followed by dietary (hence why they are called dietary or dietary aides and not “cook’s or kitchen staff”) who actually have to have safety and food handling to be dietary staff. If the dietary requirements are not followed it can be very dangerous for our residents and greatly harm or potentially kill them and what purpose would that serve? Also to address the issue of stolen money from residents they do not keep money in their rooms or on their person’s so it cannot be misplaced or claimed by someone else, resident money is clearly labeled with their names, counted and signed by multiple registered staff and locked in a safe.. I understand people’s anger and frustration with nursing home staffing and conditions and how the government gets a majority of the blame however they can throw as much money at it as they want but if resources such as available staffing or time isn’t there all the money in the world is not going to make a difference. With the types of things you are claiming especially revolving around theft and diet I would like to know the names of said places and why they have not been reported to the ministry of long term care, have you contacted them with these claims to have it investigated?

  • Emma-Lee Chase says:

    I currently live in Kingston Ontario. We have a medical school and university nursing school. The nursing school trains nurse practitioners (NPs). Sadly, a good number of these graduates will either be returning to their hometowns, large metro areas such as Toronto and Ottawa or they will go to the United States after graduation. Current estimates are that we have 30,000+ people in Kingston with no family doctor. Helping NPs set up independent practices would be a solution to this issue. It costs the system much more money to allow modifiable factors in health conditions to exacerbate and then treat people in crisis at the emergency room. When is Ontario going to come up with a realistic, detailed and responsive and plan about Primary Care for underserviced communities? Also, we should be training local students (MD, RN, NP) who will actually remain living in the community, after graduation…

    • Dee says:

      I too live in Kingston and I whole hearted agree with your statement, I do think it’s amazing the government is stepping up and paying for the Psw course and Psw’s to be trained however I as a psw would like to continue my education to become a RPN and yes stay within the area but I would also like to see the government step up and not necessarily pay for the course but offer a accelerated course at a lesser cost, or gurentee funding assistance so you cannot get denied by osap, offer child care (as I am a mother of a toddler and know others are going to have a hard time finding child care), but not just for Psw’s and Rpn courses all medical courses in need right now Rn’s and Np’s as well. Not to over flood the medical system but it does not look as thought this pandemic is coming to a end any time soon and who is to say what is next

  • Elizabeth Graham says:

    Agree totally. When working as Nurse Manager in LTC we used and appreciated our NPs daily.
    Please ensure this article gets on the front pages of all print media in the country.

  • Deborah Burne says:

    Excellent article and the path to ensure best practice care in LTC Congrats Cathy Just remembering our Delirium Best practice standard development work.
    Deborah Burne RN,BA.(Psych)
    Fac Health and Social Sciences
    Sheridan College

  • Deborah Cooper NP says:

    Great representation of what NPs are doing and what they can do in the future in LTC.

Authors

Katherine S. McGilton

Contributor

Katherine S. McGilton, RN, PhD, FAAN, FCAHS, has conducted research in long-term care homes for more than 20 years. She is a senior scientist, KITE, Toronto Rehabilitation Institute, UHN, and a professor at Lawrence S. Bloomberg, Faculty of Nursing, University of Toronto.

Dana Cooper

Contributor

Dana Cooper, MBA, CAE, is the executive director of the Nurse Practitioners’ Association of Ontario, the representative organization for NPs in Ontario.