As a 24-hour-a-day, seven days a week, on-call nurse practitioner serving elderly and frail patients, my work day is anything but typical. I start my day not at a hospital or clinic, but at my dining room table. There, I document patient visits from the day before, write up my notes and place an average of 10 or more calls—ranging from setting up appointments to calling my patient’s family members for an update on how they’re doing to checking in with the various members of my patients’ healthcare teams.
I always have three patient appointments scheduled each day, which take place in the patient’s home, where it’s most convenient for them. Sometimes it’s to follow-up on a patient who was sick to make sure they’re feeling better, or to check in on a diabetic patient to make sure they’re managing their insulin appropriately. I also might accompany a patient who is having a hard time managing their diabetes on a trip to an endocrinologist to ensure the patient and I both understand the specialist’s recommendations to avoid any confusion down the road. In between my planned visits, I’m in constant communication with each patient’s interdisciplinary healthcare team, which includes a primary care physician, physical therapy, behavioral health and social services professionals.
Then there are the unexpected visits, which I always leave room for. And they always happen. Consider this example:
“Laura, this is Maria. My mother has a fever and is nauseous,” says the daughter of my 79–year-old patient, Rose. “I’ll be right over” is my easy and immediate answer.
I jump back in my car and drive from Natick, MA to the Cambridge senior housing complex where Rose—one of my frailest patients—lives takes about 45 minutes. When I go up to the apartment to see her, she indeed has a fever. She also has the chills, is nauseous and has been feeling a burning sensation when she urinates. I have my lab supplies with me and take a urine sample right away. The white blood cells in the sample indicate Rose has a urinary tract infection (UTI), so I call in a prescription for an appropriate antibiotic, and her daughter picks it up at the pharmacy across the street. The time from Maria’s initial call to the time of treatment for a UTI is approximately one hour and 30 minutes, and Rose didn’t even need to leave her home.
If Rose got her healthcare solely from a traditional practice, her flare-up could have easily spiraled downward. Her daughter called late in the day, a time when the doctor’s office would have been closed. She would have spoken to an on-call clinician who would likely have directed her to the emergency room, especially if there was no after-hours urgent care available. If she tried to get an appointment to see her primary care physician, she could have seen a wait time of several days, meaning her infection could have potentially worsened to something more serious.
Whether a patient is having problem with insulin management, or is experiencing abdominal pain, when there’s an acute issue we teach patients like Rose to call us before they go to the emergency room. As a nurse practitioner I am able to assess, order lab tests, diagnose and prescribe medication, and care for a wide range of acute issues in the home allowing our patients to avoid hospital visits that could lead to further complications. But my ability to provide home-based care achieves more than just reducing expensive ER visits.
Typically a primary care physician, nurse practitioner or physician assistant in an office setting sees approximately 20 to 24 patients per day and gets about 15 minutes to see the patient and document the visit, whereas I’m able to spend as much time as needed with a member in their own home to make sure they gets the care they need, understand the medication that’s been prescribed and know how to use any medical equipment. I have the opportunity to develop this relationship with all of my patients and am able to supplement their care with additional resources as I and the team see fit. I’m not bound by insurance policies and procedures, and red tape; my charge is simply to provide the care and resources my patient needs.
I feel fortunate to participate in a unique model of care that allows me, along with my care teams, to be very effective and focus on preventive measures. I feel like my work is improving lives. My patients are survivors. They didn’t get to be this age without overcoming their share of challenges, and they deserve to receive the highest quality of evidenced-based primary care. My days may be far from typical, but it’s worth it to be able to be the first line of defense in helping them sidestep exacerbations, and avoid hospitalization, live-in nurses, nursing home admissions and all of the medical complications that are associated with inpatient admission.
Laura Black is a nurse practitioner for Commonwealth Care Alliance.
