Physician Assistant Practice in Long Term Care Facilities

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Physician assistants practice medicine with physician supervision in a wide range of health care settings, from the operating room to rural clinics. Increasingly, physician assistants (PAs) are found caring for patients in long term care facilities. Practice in a long term care facility, often part of a specialization in geriatric or rehabilitation medicine, is both challenging and rewarding for many PAs. Physician assistants’ generalist training and emphasis on patient relationships make them particularly valuable in the long term care environment. Physician-PA teams offer a mix of skills that matches well with the needs of long term care patients. As more PAs move into this practice area, patients, physicians, facilities, and PAs themselves have much to gain. At the same time, PAs and employers should recognize how facility policy and state and federal regulations affect PA practice in the long term care setting.

The PA Profession

More than 40 years ago, physicians first developed the concept of PAs. These innovators recognized that highly trained assistants could enable physicians to treat more patients and make better use of practitioners’ time and skill levels. Today, there are more than 60,000 PAs practicing in the U.S., and an increasing number of them serve residents of long term care facilities.

PA training is medically rigorous. Admission to a PA training program requires roughly two years of science-based college coursework prior to application. After enrolling in a PA program, students study the basic medical sciences and physical examination techniques, followed by a clinical phase of training that includes classroom instruction and clinical rotations in primary care and several medical and surgical specialties. Accreditation standards call for PA programs to provide clinical experiences in the long term care setting.1  Overall, the PA student completes over 2,000 hours of supervised clinical practice prior to graduation. The didactic and clinical training takes an average of 26 months.

All states license PAs to perform medical and surgical care as delegated by a physician, while the federal government credentials PAs it employs to provide physician-delegated services. Physicians delegate functions that are within the physician’s scope of practice, part of the PA’s training and experience, allowed by state law, and consistent with facility policy. These duties may include performing physical examinations, diagnosing and treating illnesses, ordering and interpreting lab tests, assisting in surgery, and making rounds at facilities such as nursing homes. PAs may prescribe drugs when physicians delegate this authority.

PAs’ Skills Help Meet the Varied Needs of Long Term Care Patients

PAs perform all of these duties in long term care settings and their primary care training serves patients well in this area. Long term care residents often exhibit chronic conditions with episodes of need for more intensive interventions. Due to the many demands on their time, physicians’ visits to long term care facilities often must be devoted to the most acute patient conditions. The long term care population, though, exhibits many chronic conditions from diabetes to hypertension to Alzheimer’s Disease. PAs have the skills to perform the evaluation and management functions that are vital to effective treatment of these and other chronic conditions. At the same time, physician-PA teams are well suited to treat infections, skin conditions, bone fractures, and other maladies that require more immediate diagnosis and treatment. PAs’ well-developed assessment skills are an important asset—PAs have the knowledge and judgment to evaluate quickly the level of care needed. They can treat many of these acute problems immediately; for those that require physician-level care, their established relationship with a supervising physician allows for timely attention from the physician.     

By applying their complementary skills appropriately, a physician-PA team can tackle the needs of a much larger group of long term care patients than a physician alone. A team approach assures that patients receive the most appropriate level of care, allowing physicians to spend more time on the most complex cases while increasing the total number of patients who receive required medical attention.2 

Because they often have the opportunity to spend more time at a long term care facility than a busy physician, PAs can provide a range of additional benefits. They can coordinate the care delivered by a range of specialized practitioners or take the time to communicate with patients’ families. PAs can focus on improving the quality of care delivered by the facility. They can oversee the training of other facility staff on medical issues. PAs can also aid in the provision of palliative care to patients whose conditions may no longer be responsive to medical interventions.   

Responding to this match between medical needs and PAs’ skills, physicians have developed effective ways to use PAs in long term care. A PA working in the long term care setting may be employed by or contract with a long term care facility, a medical practice associated with a facility, or a physician who provides care to a facility’s residents.3  While physicians are required by federal and some state regulations to see patients every 30 to 60 days, they often find it difficult to make additional visits to evaluate the ongoing care of a resident. To assure quality resident care, physicians or groups of physicians often utilize PAs to achieve more frequent visits, provide follow up care, and treat acute problems.4  The physician-PA team in the long term care setting provides consistency in care, better access to medical input when problems arise, and improves the information physicians receive. Such attention ultimately facilitates better decision making, a reduction in emergency room trips, and fewer hospitalizations.5

Studies Show PAs’ Value in Long Term Care

Research on physician assistant utilization in long term care has confirmed some of the benefits associated with PA utilization. Studies reveal that when a PA was added to a long term care facility’s medical team, the amount and quality of care residents received increased.6  Other studies have shown that the introduction of a PA to nursing home medical teams both increases the medical attention (measured by visits and medical orders) that patients receive and decreases the hospitalization of patients by as much as 38%.7 Additionally, PAs provide care to residents of long term care facilities at a cost less than physicians, and generally spend more time interacting with residents. This interaction allows for timely identification of treatable conditions before they become severe.

Regulation of PAs in Long Term Care Practice

As the utilization of PAs has increased in long term care, Medicare and Medicaid have established regulations regarding reimbursement for their services. PAs may perform medically necessary services within the scope of practice defined by state law in all care settings. However, only physicians can perform the full comprehensive visit in Skilled Nursing Facilities (SNFs), and PAs may not sign the initial certification or recertifications for SNFs. Physicians may delegate to PAs alternating follow-up visits in a SNF. For nonskilled nursing facilities, PAs may perform initial comprehensive visits, follow-up visits, and certifications as long as the PA is not directly employed by the facility.

State laws and regulations, as well, have come to recognize the contributions of physician assistants in long term care settings. States often require that long term care patients are evaluated upon admission, that they have the opportunity to identify an attending medical provider, or that they are seen by a provider with a specified frequency. Several states specify that PAs may provide one or all of these services to long term care patients. Since not all states have each of these provisions in their regulations, though, PAs and their employers should verify state laws and rules when undertaking long term care practice.

Conclusion

Using physician assistants to extend care to patients in long term care is in keeping with the profession’s tradition of improving access to care for those underserved by medical resources due to social, geographic, or economic factors. From its creation, the PA profession has been intended to both improve the quality of care and combat shortages of highly-trained medical practitioners. Working in long term care facilities allows PAs to fulfill both of these goals. As the number of patients in long term care increases and the acuity of their conditions intensifies, the medical resources to address these needs have been strained. PAs can fill an important role in providing medical services to this population.   

Issue Brief: PA Practice in Long Term Care Facilities

11/07

1. Accreditation Review Commission on Education of the Physician Assistant. Accreditation Standards for Physician Assistant Education, Third Edition, October 2007.
2. Bottom, Wayne PA-C. “Geriatric Medicine in the United States: New Roles for Physician Assistants”. Journal of Community Health, Volume 13, number 2. Summer 1988.
3. Segal-Gidan, Freddi I. PA, PhD. “The Role of PAs in Caring for the Elderly”. Journal of the American Academy of Physician Assistants, Volume 10, number 4; April 1997.
4. Ouslander, Joseph M.D., Osterwiel, Dan, M.D. “Physician Evaluation and Management of Nursing Home Residents.”  Annals of Internal Medicine, Volume 120, Number 7; April 1994
5. Ouslander & Osterwiel.
6. Sorem, Kevin R. PA-C. and Portnoy, Valery A. M.D. “Decreased Rates of Polypharmacy, Hospitalization and Mortality through Geriatric Medical Team Involvement in a Nursing Home”. May 1983.
7. Caprio, Thomas, M.D. “Physician Practice in the Nursing Home: Collaboration with Nurse Practitioners and Physician Assistants.” Annals of Long-Term Care, Volume 14, Number 3; March 2006.