Nurse Practitioners at Home

*All names have been changed to protect privacy

When Karen Hiensch ’10 ’12 read the note referring her new patient Rinaldo Ramos, her first thought was, “What am I supposed to do?”

The 87-year-old gay Cuban émigré had just been discharged from the hospital following a urinary tract infection and a small-bowel obstruction. He also suffered from uncontrolled diabetes. He had been sent home with no insulin because cognitive impairment made him unable to focus, check his sugar levels, or administer the insulin on which his life depended. He had no family or support and refused a home attendant.

“It was like sending him into a storm without a rowboat or life preserver,” Hiensch said during her biweekly home visit with Ramos, one of three patients she regularly cares for in East Harlem. A nurse practitioner (NP) on Mount Sinai’s IMA PACT (Preventing Admission Care Team), Hiensch sees patients at both the Mount Sinai clinic and in their homes. “Patients who are at high risk for lots of ER visits or high readmission rates get referred to us,” she explained.

Ramos was originally referred for clinic visits, but Hiensch went to see him at home “to get the real story.” In fact, his neatly tended, artistically decorated apartment—walls filled with clocks and paintings, baskets overflowing with artificial flowers—was the biggest part of the story for Hiensch. She had previously thought he should be in a nursing home. But seeing the pride he took in his home, she realized that “being sent to an institution would take all the pleasure out of his life.” She arranged for a daily visiting nurse to administer Ramos’ insulin, and she persuaded him to accept a home attendant for two hours a day. Together, they were able to get his diabetes under control. For more than a year now, he has been enjoying his routines, reading his newspaper at the local McDonald’s or on a sunny park bench every afternoon. But this visit by Hiensch followed her patient’s five-day hospitalization after a fall left him with a brain hemorrhage and pneumonia—his first readmission in the year since Hiensch took him on as a patient.

Speaking in Spanish and gesticulating broadly, Ramos tells her that he fell only because he vomited after eating bad food, and then slipped.   

Gently, in the Spanish she learned from middle school through college and in work/study trips throughout Latin America, Hiensch quizzes him about the fall, explains why he needs the pills for the bleeding in the brain, and why he must keep taking the antibiotics. As he complains about the $25 for the pills, Hiensch plays detective. She suspects he blacked out from low blood sugar and wants no repetition. “Have you eaten today?” she asked. “Do you have food?” She opens his refrigerator and closes it. “Oh, dear.”

“Where’s your home attendant?” Hiensch asked. She discovers he’s been sent home by Ramos, leaving her patient with no home help at all. “This is not acceptable,” she said. “I will fix this.”

Before she leaves, there is other business: a physical exam, yet another discussion of signing a health care proxy, and an examination of his ostomy bag (from colon cancer). She tells him he must have more attendant hours. He acquiesces—unhappily.

“He could have fallen again,” Hiensch said on the way to her next patient. “He’s unsupervised; he’s not taking his meds. He’s not well nourished. This is not acceptable.” By the end of the day, Ramos has been approved for eight hours a day of home attendant services to start the next morning.

Hiensch is among the thousands of nurse practitioners now revolutionizing home care, an increasingly critical piece of the health care picture in the United States. As hospitals are driven to discharge patients more quickly and to reduce preventable readmissions, more than 33,000 home health providers are caring for an estimated 12 million Americans at an annual cost of more than $72 billion.

The advantages of having NPs lead home health care teams have become so evident that at least 17 states have given them full supervisory authority over patient care in the home setting. At the same time, there is a powerful movement to remove requirements for physicians to oversee the powers of NPs to write prescriptions and home care orders. 

Nurse practitioners such as Hiensch are delivering and coordinating care in all phases of a patient’s span of illness, from diagnosis to hospital to home to cure, or death. Some are heading up major institutions and influencing policy to better serve patients. Directing teams that include RNs, home health aides, and social workers, NPs are bringing evidence-based medicine into people’s homes. Some are researching the best ways to improve care at home. Others are agency owners or managers, directing their organizations toward all of these ends. These advanced-practice nurses are lifelines not only for their patients but for their patients’ families, addressing deep emotional and spiritual needs.

As the health care system undergoes profound changes, advanced-practice nurses are ideally positioned to lead the way forward, says Marlene McHugh, DNP, assistant professor at Columbia Nursing and associate director of the Palliative Care Service at Montefiore Medical Center.

“We know which patients are at risk for readmission,” McHugh said, “those with congestive heart failure, pain from cancer and treatment, and psychosocial problems.”

“Psychosocial problems” cover the vast array of everyday difficulties and emotions that nurse practitioners, because of their nursing education, are well suited to spot and administer to. “Equally important,” said McHugh, “they recognize when collaboration with social work colleagues is needed.” Such instances may include a patient with high blood pressure too frustrated by the system to obtain her medications, a hip replacement patient living in a fifth-floor walk-up without help, and a cancer patient in pain who feels scared and lonely. Bringing RNs and NPs with palliative care education more widely into the home, McHugh says, would reduce unnecessary ER visits and readmissions, although reimbursement obstacles make this sometimes difficult to achieve.

Increasingly, though, as NPs ascend to top leadership positions at major institutions and organizations, they are poised to influence policy. “Nurse practitioners who can understand the day-to-day workings of transitions in care,” McHugh said, “are now present at the table.”

Wherever they work in the system, “NPs can be change agents,” said Amy Ansehl '94 '96, assistant dean and associate professor of public health practice at New York Medical College, and vice chair, Board of Directors for Visiting Nurse Services of Westchester (VNSW).

In 2002, for example, Ansehl and Mary Gadomski, an RN from VNSW, spearheaded a stop-smoking initiative for its home patients. At the start, Ansehl, then executive director of the Partnership for a Healthy Population at New York Medical College and chairperson of POW’R Against Tobacco, an anti-smoking coalition based in the New York City suburbs, met a roadblock. Nurses were not asking patients they treated for wound care or hypertension whether they smoked or would like counseling to quit. Why? The questions were not part of federal (OASIS) intake forms.

The 600 patients that VNSW saw a month were not being screened for smoking and were at potential for being harmed. We asked, Ansehl recalled, “How can we change this?

“We led the VNSW in a policy change to improve the health of the homebound population,” Ansehl said. In the new policy, in addition to questions on the federal form, every nurse would ask every patient they saw at home whether they smoked, how often, and whether they were interested in quitting. The nurses would also give them education about tobacco’s harmful effects and strategies for quitting.

“We got all the organizations to the table,” Ansehl said. “POW’R gave feed funding for VNSW to develop a program to intervene, question, educate, refer patients to anti-smoking programs, and follow-up. The program they developed was implemented and proved sustainable. 

“Since then,” said Ansehl, “we’ve screened, provided education, and follow-up referrals as needed for 84,000 patients. This is true patient advocacy.

“At Columbia Nursing,” she added, “we are trained to create change. It is in our blood.”

Other advanced-practice nurses create change as researchers and nurse-scientists. Jingjing Shang, PhD, assistant professor at Columbia Nursing, for example, has identified several high risks for infection among patients at home, especially those who have urinary catheters, tracheotomies, or receive nutrients through an intravenous catheter. These tubes, often in place for long periods, can become infected when untrained caregivers don’t know how to keep them clean and unobstructed. For example, Shang never forgot a home patient she followed briefly during her training for her master’s degree. He was a relatively healthy middle-aged man who had a tracheotomy tube in his throat following neck surgery. At his apartment, she saw clutter everywhere: a sink so piled with encrusted dishes it left no room to wash hands. The patient’s friend barely listened when Shang explained how to care for his trach. “Two weeks later,” she recounted, “I found out he died from infection.”

Nurses, Shang says, need to teach patients and caregivers these skills in ways they can understand.

Research from home care practitioners is playing a large role in improving how care is delivered. Nurses at Visiting Nurse Services in Westchester, for example, are presenting posters at professional meetings and conventions and writing articles about what makes a difference, Ansehl says. Topics include wound care dressings that work best at minimizing infections and factors that prevent rehospitalizations.

Funmi Aiyegbo, DNP,’98, is a manager in the burgeoning field of telephone-based care. She leads a team of six NPs at OptumHealth who provide care advice via the phone to 3,000 home health and nursing home patients enrolled in Medicare or Medicaid in Delaware and Pennsylvania. The group is currently conducting research on several topics, including comparing the outcomes of patients with hip fractures who opt for palliative care versus those who undergo surgery. When people ask if their mother should have surgery, Aiyegbo wants to be able to offer evidence-based answers.

From her post at a computer with access to numerous patient medical records, Aiyegbo takes calls from nurses who phone in about patients’ new developments—fever, pneumonia, deteriorating cognitive status. From their assessments, she diagnoses and manages the patients, consults their advance care plan, and discusses possible interventions with the patients’ families. She also deals personally with patients who have urgent problems on nights and weekends. She loves her job because she finds it “challenging to think on my feet.”

That she does. Sometimes it’s a late-night call to wake the son or daughter of a dying mother to ask, “Would your mom want treatment? Or to be comfortable and let nature take its course?” Sometimes she has to make difficult decisions, as in the recent request of a highly anxious woman with COPD to refill her Ativan for anxiety, claiming she’d used it up due to a “family emergency.”

“We heard her voice,” Aiyegbo said, “and she’s clear and organized over three different calls. I didn’t feel this was a real emergency.” She told the patient to visit urgent care or wait to see her provider. “It was a judgment call,” Aiyegbo said. “This job is not for new NPs. You need to learn how to interview over the phone and make decisions with confidence.”

Confidence, sensitivity, imagination, and organizational skills bordering on the magical are required by home-visit NPs, who must deal with both the medical needs of their patients and the emotional and social needs of their families. Maura Del Bene ’99, a psychiatric NP and director of palliative medicine at WESTMED Medical Group, recently managed a case that called for all of the above.

The father, Jim, 88, was dying of colon cancer; he was also blind and slightly demented. Recently widowed, he lived with his 62-year-old son, Neil, who was developmentally disabled  paranoid, and aggressive and had never lived apart from his parents. Jim’s other son, Andy, 66, a physician, believed Neil, never certified as disabled, should live in a group home. To attend to this caldron of needs, Del Bene marshaled a team of social workers, pastors, and two 24/7 live-in aides for Jim and Neil.

One fall afternoon, Jim’s condition took a bad turn. When Del Bene arrived, she saw Jim’s ashen skin, slowed breathing, and other signs that death was imminent. While Neil paced, screaming accusations about what “they” were doing to his father, Del Bene called Andy to come. She assured him that, whatever happened, she’d stay with Neil.

 “Your father is comfortable,” she said gently to the frantic Neil. “He’s not suffering.” A few minutes later, she said, “Your dad’s stopped breathing.”

“So he’s dead,” Neil concluded, pacing even more frantically.

Del Bene calmed him. “Is there someone you want to call?” she suggested. 

 “It’s my job to tell them Dad died,” Neil declared, and he began to take comfort in taking charge.

When Andy arrived and wanted time alone with his father, Del Bene kept Neil away, with difficulty. The maternal Jamaican aide who’d developed a rapport with Neil put out her arms to him—usually, no one could touch him—and he fell into her embrace, sobbing. 

Del Bene knew that Neil was frightened of and hostile toward police. Because Jim was not officially in hospice, a patrol car would inevitably pull up. So she made calls, pulled strings, and was able to keep the officers away.

Now, a few months later, because of Del Bene’s initiatives, Neil is interacting better with his aides, has registered to become eligible for benefits, and may enter a group home the team has found for him.

“In my 20 years of practice,” Del Bene said, “this was the most emotional case I ever experienced. In his eulogy at the funeral, Andy thanked us: ‘We were praying for a miracle,’ Andy said, ‘and the miracle was to have a nurse practitioner with my brother Neil as Dad was dying.’”

Nurse practitioners such as those in this story are having similarly powerful effects on the patients they care for, as well as their families, every day throughout the United States. As people live longer and policy changes place an increasing emphasis on shortening hospital stays, NPs are certain to see their involvement in all aspects of patient care continue to rise. Columbia Nursing is playing a major role in preparing NPs for this new reality, and this part of its mission will continue to grow.