Latest news with #nursePractitioner
Medscape
20-06-2025
- Health
- Medscape
Nurse Practitioners Fill Gaps as Geriatricians Decline
On Fridays, Stephanie Johnson has a busy schedule, driving her navy-blue Jeep from one patient's home to the next, seeing eight in all. Pregnant with her second child, she schleps a backpack instead of a traditional black bag to carry a laptop and essential medical supplies — stethoscope, blood pressure cuff, and pulse oximeter. Forget a lunch break; she often eats a sandwich or some nuts as she heads to her next patient visit. On a gloomy Friday in January, Johnson, a nurse practitioner who treats older adults, had a hospice consult with Ellen, a patient in her 90s in declining health. To protect Ellen's identity, KFF Health News is not using her last name. 'Hello. How are you feeling?' Johnson asked as she entered Ellen's bedroom and inquired about her pain. The blinds were drawn. Ellen was in a wheelchair, wearing a white sweater, gray sweatpants, and fuzzy socks. A headband was tied around her white hair. As usual, the TV was playing loudly in the background. 'It's fine, except this cough I've had since junior high,' Ellen said. Ellen had been diagnosed with vascular dementia, peripheral vascular disease, and type 2 diabetes. Last fall, doctors made the difficult decision to operate on her foot. Before the surgery, Ellen was always colorful, wearing purple, yellow, blue, pink, and chunky necklaces. She enjoyed talking with the half dozen other residents at her adult family home in Washington state. She had a hearty appetite that brought her to the breakfast table early. But lately, her enthusiasm for meals and socializing had waned. Johnson got down to eye level with Ellen to examine her, assessing her joints and range of motion, checking her blood pressure, and listening to her heart and lungs. Carefully, Johnson removed the bandage to examine Ellen's toes. Her lower legs were red but cold to the touch, which indicated her condition wasn't improving. Ellen's two younger sisters had power of attorney for her and made it clear that, above all, they wanted her to be comfortable. Now, Johnson thought it was time to have that difficult conversation with them about Ellen's prognosis, recommending her for hospice. 'Our patient isn't just the older adult,' Johnson said. 'It's also often the family member or the person helping to manage them.' Nurse practitioners are having those conversations more and more as their patient base trends older. They are increasingly filling a gap that is expected to widen as the senior population explodes and the number of geriatricians declines. The Health Resources and Services Administration projects a 50% increase in demand for geriatricians from 2018 to 2030, when the entire baby boom generation will be older than 65. By then, hundreds of geriatricians are expected to retire or leave the specialty, reducing their number to fewer than 7600, with relatively few young doctors joining the field. That means many older adults will be relying on other primary care physicians, who already can't keep up with demand, and nurse practitioners, whose ranks are booming. The number of nurse practitioners specializing in geriatrics has more than tripled since 2010, increasing the availability of care to the current population of seniors, a recent study in JAMA Network Open found. According to a 2024 survey, of the roughly 431,000 licensed nurse practitioners, 15% are, like Johnson, certified to treat older adults. Johnson and her husband, Dustin, operate an NP-led private practice in greater Seattle, Washington, a state where she can practice independently. She and her team, which includes five additional nurse practitioners, each try to see about 10 patients a day, visiting each one every 5-6 weeks. Visits typically last 30 minutes to an hour, depending on the case. 'There are so many housebound older adults, and we're barely reaching them,' Johnson said. 'For those still in their private homes, there's such a huge need.' Laura Wagner, a professor of nursing and community health systems at the University of California, San Francisco, stressed that nurse practitioners are not trying to replace doctors; they're trying to meet patients' needs, wherever they may be. 'One of the things I'm most proud of is the role of nurse practitioners,' she said. 'We step into places where other providers may not, and geriatrics is a prime example of that.' Practice Limits Nurse practitioners are registered nurses with advanced training that enables them to diagnose diseases, analyze diagnostic tests, and prescribe medicine. Their growth has bolstered primary care, and, like doctors, they can specialize in particular branches of medicine. Johnson, for example, has advanced training in gerontology. 'If we have a geriatrician shortage, then hiring more nurse practitioners trained in geriatrics is an ideal solution,' Wagner said, 'but there are a lot of barriers in place.' In 27 states and Washington, DC, nurse practitioners can practice independently. But in the rest of the country, they need to have a collaborative agreement with or be under the supervision of another health care provider to provide care to older adults. Medicare generally reimburses for nurse practitioner services at 85% of the amount it pays physicians. Last year, in more than 40 states, the American Medical Association and its partners lobbied against what they see as 'scope creep' in the expanded roles of nurse practitioners and other health workers. The AMA points out that doctors must have more schooling and significantly more clinical experience than nurse practitioners. While the AMA says physician-led teams keep costs lower, a study published in 2020 in Health Services Research found similar patient outcomes and lower costs for nurse practitioner patients. Other studies, including one published in 2023 in the journal Medical Care Research and Review , have found healthcare models including nurse practitioners had better outcomes for patients with multiple chronic conditions than teams without an NP. Five states have granted NPs full practice authority since 2021, with Utah the most recent state to remove physician supervision requirements, in 2023. In March, however, Mississippi House Bill 849, which would have increased NP independence, failed. Meanwhile, 30 Texas physicians rallied to tamp down full-scope efforts in Austin. 'I would fully disagree that we're invading their scope of practice and shouldn't have full scope of our own,' Johnson said. She has worked under the supervision of physicians in Pennsylvania and Washington state but started seeing patients at her own practice in 2021. Like many nurse practitioners, she sees her patients in their homes. The first thing she does when she gets a new patient is manage their prescriptions, getting rid of unnecessary medications, especially those with harsh side effects. She works with the patient and a family member who often has power of attorney. She keeps them informed of subtle changes, such as whether a person was verbal and eating and whether their medical conditions have changed. While there is some overlap in expertise between geriatricians and nurse practitioners, there are areas where nurses typically excel, said Elizabeth White, an assistant professor of health services, policy, and practice at Brown University. 'We tend to be a little stronger in care coordination, family and patient education, and integrating care and social and medical needs. That's very much in the nursing domain,' she said. That care coordination will become even more critical as the US ages. Today, about 18% of the US population is 65 or over. In the next 30 years, the share of seniors is expected to reach 23%, as medical and technological advances enable people to live longer. Patient and Family In an office next to Ellen's bedroom, Johnson called Ellen's younger sister Margaret Watt to recommend that Ellen enter hospice care. Johnson told her that Ellen had developed pneumonia and her body wasn't coping. Watt appreciated that Johnson had kept the family apprised of Ellen's condition for several years, saying she was a good communicator. 'She was accurate,' Watt said. 'What she said would happen, happened.' A month after the consult, Ellen died peacefully in her sleep. 'I do feel sadness,' Johnson said, 'but there's also a sense of relief that I've been with her through her suffering to try to alleviate it, and I've helped her meet her and her family's priorities in that time.'
CTV News
20-06-2025
- Health
- CTV News
Ontario's measles outbreak through the eyes of front-line workers
Emergency department charge nurse David Lambie outside the emergency entrance of the Woodstock General Hospital in Woodstock, Ont., Thursday, May 22, 2025. THE CANADIAN PRESS/Nicole Osborne ST. THOMAS — Health-care workers battling measles in southern Ontario say they think about the outbreak from the moment they wake until the moment they sleep. They say treating and tamping down the surge of a disease most have never seen in their lifetime is constant. Some have even been infected by patients who unwittingly spread the highly infectious illness while seeking help for early but general symptoms — fevers and coughs are common before the telltale rash appears days later. Measles has spread to more than 3,000 people in Canada this year. More than 2,000 of those infected are in Ontario. Here's a look at caregivers on the front lines of an outbreak that has particularly struck a region south and east of London. 'The unlucky ones' Carly Simpson considers herself one of the 'unlucky ones.' Five days after developing a sore throat, body aches and fever, the nurse practitioner gazed at her reflection in the bathroom mirror, stunned to see red splotches all over her body. 'Oh my gosh this is measles,' Simpson gasped. She said measles never crossed her mind when she first fell ill mid-March, suspecting a more likely cause was her autoimmune disease, ankylosing spondylitis, which leads to chronic pain and inflammation. After all, the vast majority of cases had been among the unvaccinated and Simpson said she had been inoculated three times — including a booster in 2015 after a test revealed her previous two shots didn't lend full immunity. Simpson said she had been assured at the beginning of the outbreak that three shots would be enough to protect her. She still got sick and was essentially bedridden for days, only mustering enough energy to walk to the bathroom. But she said the rash only lasted a day and never spread to her husband or kids. 'I had a mild case because I've been vaccinated,' said Simpson, among five per cent of the outbreak's cases to involve vaccinated people. She suspected she was infected by a patient who came to her clinic with virus symptoms a couple of weeks earlier. Early symptoms can seem like other illnesses until the rash appears, leaving health-care workers who examine them vulnerable to exposure. 'Is this just a common cold? Is it just some viral infection?' she said of the questions that dog caregivers. Shawn Cowley was unlucky, too. He noticed white spots inside his cheeks in late April, and then a red blotchy rash on his forehead that migrated down his face, and onto his shoulders and arms. 'Fortunately for me, because I was fully vaccinated I didn't get the full brunt of measles,' he said, explaining that the rash otherwise would have covered his whole body. Still, it took about a week for his body to recover from the exhaustion. Cowley is a key player in measles containment as head of emergency management and preparedness at the local health unit, Southwestern Public Health. His case was traced to his son's hockey tournament. He eventually told his colleagues that he contracted measles but noted there is 'a stigma' associated with the illness. Cowley also felt guilty for going to the grocery store and filling up on gas before he was symptomatic, potentially spreading it to others. 'When you find out you do potentially have measles, and the number of people I've exposed, understanding how virulent measles is, that's a really hard thing to deal with personally because you put other people at risk.' 'Slow burn' Dr. Erica Van Daalen calls the outbreak a 'slow burn' but one that has required close collaboration among local hospitals to safely treat and isolate measles patients. The chief of staff at St. Thomas Elgin General Hospital said she might see one to three patients in the emergency department on an average day, and often they are children. As of late May, three infected pregnant women had delivered babies and 15 kids had been admitted. Those include young patients transferred from hospitals in Woodstock and Tillsonburg, which don't have pediatric units. 'It's a lot of one-on-one bedside nursing,' Van Daalen said in an interview earlier this spring. 'When the days are busy, it wears on the nurses.' Less than seven per cent of Ontario's cases have ended up in hospital. But the logistics of safely admitting a measles patient is like expert-level Tetris. Masked patients are ushered through back doors to negative pressure rooms that keep contaminated air from escaping into other areas of the hospital and infecting more people. The room is sealed and has a system that filters and exchanges the air. Exposure risks are avoided as much as possible, even trips to the bathroom, said Sangavi Thangeswaran, a registered nurse and an infection control practitioner at both Alexandra Hospital Ingersoll and Tillsonburg District Memorial Hospital. 'We ask the patient to stay in there. If they need anything like using the washroom, we try to give them commodes or urinals, just to lessen the exposures,' Thangeswaran said. There are five negative pressure rooms at Woodstock Hospital. When they're full, patients are assessed in the ambulance garage, said David Lambie, a charge nurse in Woodstock's emergency department. It is an extra layer of logistics to navigate, said Lambie, whose hospital has cared for 108 measles patients since January, 55 of them kids. Once a patient is well enough for discharge, their negative pressure room is left empty for half-an-hour while contaminated air is expunged. Then it's deep cleaned for the next patient, said Thangeswaran. She said each of her Oxford County hospitals initially had just one negative pressure room in each emergency department but as cases swelled they created three more. As of June 12, her team had cared for 14 measles patients in Ingersoll and 64 in Tillsonburg. 'Inherent challenge' Van Daalen, of the hospital in St. Thomas, said deciding whether to discharge a kid sick with measles sometimes keeps her up at night. 'You hesitate to send them home because you're not quite sure how they're going to land,' she said. 'There are some later-term consequences for kids who have measles. It's a very rare complication, but we'll have to keep our surveillance up.' Dr. Ninh Tran said he felt like he was approaching burnout in late February. Ontario's weekly case count had nearly doubled to 177 over a two-week period ending Feb. 27, with almost half of the overall cases located in his southwestern public health unit. Pressure was high to trace cases, halt community spread and stop infections. Measles was on his mind every moment of the day and night. 'You could sense a bit of tension and anxiety in all this discussion,' Tran recalled in late May. 'It's always like a temporary feeling of doubt, fear, anxiety when we see numbers go up and there's just a lot of things coming right at you,' Tran said of the outbreak's early days. 'And then you have to step back and say, 'OK, it's not going to be helpful if I get stressed because I need to — and other leaders have to — figure out a way to move forward.' The spread of measles has ebbed and flowed, but Tran noted a steady decline of new cases mid-June. 'While it's still early to confirm a persistent pattern, the consistency of the decrease does suggest a potential shift in the trajectory of the outbreak,' said Tran. 'We are cautiously encouraged.' This report by The Canadian Press was first published June 20, 2025. Canadian Press health coverage receives support through a partnership with the Canadian Medical Association. CP is solely responsible for this content. Hannah Alberga, The Canadian Press
Medscape
13-06-2025
- Health
- Medscape
More Hospitals Turning to Nurse Practitioners. Here's Why
Every evening, nurse practitioner (NP) Arnold Facklam arrives at South Georgia Medical Center in Valdosta, Georgia, an hour before his two physician counterparts. As an NP nocturnist, a hospitalist who works overnight, Facklam's role is to supplement the care provided by the physicians on his team. He believes he offers a valuable service to his Apogee Physicians hospitalist group, able to spend more time with patients than his doctor colleagues, who carry bigger patient loads, while freeing them up to handle more acute cases. 'Both physicians and NPs do the same tasks, but they divide them up differently,' said Facklam, a hospitalist for 18 years. 'Programs of a certain size need to bring in experienced NPs and PAs [physician assistants] that can step into the role and do the tasks to take care of the patients from admissions to discharge, and consultations.' The classic definition of a hospitalist as a primary care physician is rapidly evolving and the vast majority of hospital medicine groups today use advanced practice providers such as NPs like Facklam, for adult care, according to the Society of Hospital Medicine (SHM)'s latest industry reports. In most hospitals, NP hospitalists supplement the care their physician counterparts provide, though some small rural hospitals may staff their hospitalist programs entirely with NPs with oversight from a collaborating physician who may not be on duty at the time. Whether to reduce staffing costs or fill gaps in physician shortage areas, hospitalists are navigating a new landscape to determine the most effective use of NPs in the hospital setting. Physicians and NPs sharing hospitalist responsibilities are learning how to divide their duties, improve their professional relations, and maintain job satisfaction. Medscape Medical News consulted a handful of hospitalists about the pros and cons of the new staffing models. Value of NP Hospitalists Saving money tends to be the biggest advantage of using NPs as hospitalists. The average total compensation for NPs was $135,000 in 2023 or about 60% less than for physician hospitalists, $321,000, according to Medscape's 2024 compensation reports for physicians and NPs. Third party private insurers and the Centers for Medicare and Medicaid Services reimburse NPs at 85% of the physician rate, which can help reduce costs. Among the other benefits of using NPs, they help reduce hospital wait times and because they tend to manage fewer patients than doctors, can spend more time with them, according to research cited by the American Association of Nurse Practitioners. NPs also fill a void in patient care when hospitals have difficulty attracting physicians or are short-staffed in small or rural hospitals, which tend to be workforce shortage areas. The Health Resources & Services Administration projects a 22% staff shortage of hospital physicians by 2035. Meanwhile the US Bureau of Labor Statistics consistently reports NPs among the nation's fastest-growing occupations with a projected 46% growth rate between 2023 and 2033. Nikhil Sood, MD In the past few years, Nikhil Sood, MD, has witnessed 'a monumental' increase in the number of NPs working alongside him as a hospitalist at Banner Gateway Medical Center in Gilbert, Arizona. 'Utilizing NPs' expertise can significantly improve care delivery,' said Sood, who treats patients with cancer. NPs also can alleviate physician burnout and enhance patients' access to care, he said. 'I have partnered with NPs who are outstanding clinicians, meticulous in their work, empathetic in nature, and collaborative. They bring a nursing perspective…often identifying psychosocial or care coordination issues that might otherwise go unnoticed.' Monique Nugent, MD, MPH, appreciates the specialty care the advanced practice providers on her hospitalist team offer patients. She finds them fully capable of supplementing physician care. 'They work really well with our group. They are a huge support, and they are no less hospitalists than physician hospitalists,' Nugent said about her Advanced Practice Professional (APP) colleagues specializing in cardiac and oncology care at South Shore Hospital in Weymouth, Massachusetts. 'Patients benefit from people with a specialty and who know how to navigate medicine.' Challenges of NP Hospitalists Nugent doesn't believe hospitals should focus solely on the savings just because APPs traditionally earn less than doctors. 'You still need highly qualified people…You have to invest in the person if you want them to do good work,' she said. Hospitals should provide support such as case management, a safe patient load, and an appropriate level of malpractice insurance, Nugent said. Monique Nugent, MD, MPH 'If a hospital has 200 patients and there are 20 doctors who take care of 10 patients each, you can't replace the doctors with APPs and expect them to be comfortable caring for the same number of patients. It's not simply a math question,' she said. Staffing calculations also need to include additional administrative requirements for APPs mandated by law and whether states require physician oversight of APPs, Nugent stressed. More than half of the states give NPs full practice authority to manage patients independently of physicians, but only a handful of states offer full or optimal practice authority for PAs. 'If the system employs PAs and NPs simply because it costs less, they are missing the value they bring to the system,' she said. 'How can we support everyone in their practice so we can support the patient? I work with NPs that are really great at their job. Working that way allows us to be great,' Nugent said. John Nelson, MD, who co-founded the SHM, said hospitals may add NPs or PAs because they can't recruit doctors in rural areas, or they want to pay less for staffing. But those hospitals may not have carefully considered exactly what the APPs will do, their job description, how they will help doctors see patients, said Nelson, a hospitalist and partner in Nelson Flores Hospital Medicine Consultants. In some cases, physician hospitalists are partly to blame for the lack of direction APPs receive. The doctors are happy to gain assistance even with menial tasks and without the responsibility of paying salaries, they don't worry about wasteful spending, Nelson said. 'Hospitals are not paying enough attention to realize what is going on.' Facklam said his hospitalist program clearly defines the job responsibilities of the team. When he starts his duties at 6 PM, he works on admissions and when physicians come in at 7 PM, he provides cross coverage for the hospital and three outlying facilities. He realizes there has been a rapid increase in APPs as hospitalists created a challenging dynamic for physician hospitalists. Some understand and trust the credentials and capabilities of APPs and allow them the freedom to work effectively. But those who never worked with NPs may not know what to expect and may fear NPs will take their jobs. 'It's a work in progress,' Facklam said of physician-APP relationships. 'I think it takes time for people to realize [APPs] are qualified and capable of serving in the role they are asked to do.' But Facklam admits he may have been accepted by physicians faster than other NP hospitalists with a quicker adjustment period as a former critical and emergency care nurse and paramedic. 'I had experience that led up to it. If it was someone else, they may take a little longer to feel comfortable,' he said. Hospitals also have to navigate state and federal regulations regarding NPs, including how they can bill state and federal insurance companies and whether they need physician oversight, hospitalists said. Nearly half of NP and PA work is billed as a combination of both independent and shared services billing with the collaborating or supervising physician, according to SHM's latest State of Hospital Medicine Report. Working Effectively as a Hospitalist Team For NPs to make a smooth transition into hospitalist teams, ensuring quality and safety, requires a strategic and organized environment, Sood said. He added that such integration is particularly important when providing specialty care, such as in cancer hospitals, where there's a high rate of clinical complexity. 'Patients frequently require intricate decisions regarding chemotherapy side effects, palliative care strategies, or complications from immunotherapy. Practical experience and oncology-specific training are essential,' he said. John Nelson, MD He doesn't think NPs should be expected to operate autonomously in high-acuity or complex settings without sufficient support. 'This not only affects patient outcomes but can also create unnecessary pressure on the NPs.' A team-based approach allows NPs and physicians to regularly consult each other and manage patient care, Sood said. While NPs deserve to be respected and empowered, they also should be 'guided by clear practice scopes, mentorship, and structured clinical pathways,' he said. Nelson believes APPs can contribute professionally to the hospitalist team and find greater job satisfaction if they collaborate with physician hospitalists and receive appropriate training. In 2024, about 11% of NPs held certifications in acute care, according to AANP. Acute care generally focuses on the type of treatment patients receive in a hospital such as for accidents or emergencies. APPs also should have a 'significant say' about their roles on the team and how they could have the most impact, Nelson said. 'They should be part of the conversation if not leading it.'
New York Times
09-06-2025
- Health
- New York Times
A Day With One Abortion Pill Prescriber
The young woman's voice trembled over the phone. Sitting in her car in Alabama, where abortion is almost totally banned, the 26-year-old mother of two was grappling with an unintended pregnancy. 'I'm like 'How in the world?'' she said, stifling a sob. 'I already have two children, and I cannot. I can't. I just can't go through with it.' She wanted an abortion, she said, but was afraid of getting caught and didn't know what to expect from the process. 'Growing up, I never really thought about actually doing something like this,' she said. On the other end of the line, at home on a quiet residential street in Delaware, Debra Lynch, a nurse practitioner who runs a service prescribing abortion pills, spoke calmly. 'It's completely valid to be scared,' she said from her desk in a home office filled with plants and shelves of medication. 'And that's why we want you to call us, even if you're calling just to say: 'I'm scared. I need to hear somebody tell me that what's going on right now is normal, and it's OK.'' During the 25-minute conversation, Ms. Lynch asked the woman about her health history and pregnancy and assessed that she was medically eligible for abortion medications that can be taken in the first 12 weeks of pregnancy: mifepristone, which blocks a hormone necessary for pregnancy development, and misoprostol, taken 24 to 48 hours later, which causes contractions so pregnancy tissue can be expelled. Want all of The Times? Subscribe.
Daily Mail
21-05-2025
- Health
- Daily Mail
Haunting movement that people make just before they die - and the fascinating reason behind it, nurse reveals
If your loved one on hospice suddenly appears to reach up to the sky or ceiling at the end of their life, you're not just imagining it. For the 'unexplainable phenomenon' is 'really common' among people on the verge of death, experts have claimed. Katie Duncan, from Gaithersburg in Maryland, said the upward movement will often catch relatives off guard but patients are in fact reaching towards dead relatives, friends or even a cherished pet. While this can make it look like the dying person is in distress, she said it doesn't cause a patient to suffer. The nurse practitioner and end-of-life coach has worked in intensive care, home hospices and community and rehab facilities, caring for terminally-ill patients in the months leading up to their death. Now, she shares videos on social media on what she says she has learnt about death and dying, in the hopes of destigmatising it. In the clip, seen more than five million times, she said: 'This is one of those unexplainable phenomenons. In my personal experience working with people who are dying, this reach towards someone or something above them is really common. 'Sometimes this is associated with what we call end of life visions or other end of life experiences. 'When someone vocalises seeing someone or something, often it's an angel, sometimes it's a bright light. 'Very commonly, they say it is a loved one or family member or pet, someone who has died before. 'The person who is dying is vocalising that they're seeing this person. But sometimes you see a person reach and they don't say anything at all.' Clips of patients in their final moments have been widely shared on social media sites including TikTok and Instagram. Responding to Ms Duncan's video, TikTok users spoke about their own experiences. 'My husband did this also he reached both arms out and said mom the biggest smile I ever seen him smile,' one wrote. 'My dad saw a little boy on a white horse the night before he passed,' another said. In a separate Instagram reel seen over one million times, one woman also shared a video of her husband reaching up towards the ceiling as he drank water. 'I was so happy he was drinking I didn't even notice he was doing the before death reach to the sky,' she said. It's unclear exactly what causes terminal lucidity. However, one US study published in 2023 looking at brain activity during death suggested that dying brains are deprived of oxygen and may produce increased gamma wave activity. Gamma waves are the fastest brain waves, which occur when patients are highly alert and actively processing sensory information. Experts also believe the brain releases a flood of neurotransmitters like serotonin right before death, which could improve mood. Ms Duncan also said: 'What should we be doing about this reach? Nothing. It's one of those mystical parts of the dying process that we are able to be a witness to. 'We also know that other end of life visions and experiences tend to bring the dying person a lot of peace and comfort. 'If you're a loved one who's witnessing this in your dying person, I hope that you can let it bring you comfort.'
