Collaboration and the physician/advanced practice nurse team.

To the Editor: The recent editorial titled ‘‘Advanced Practice Nurses and Attending Physicians: A Collaboration to Improve Quality Care in the Nursing Home,’’ highlighted several aspects of nursing home care involving the advanced practice nurse (APN). We would like to make some general comments with respect to this area and then finish with some more specific points addressed to the editorial and clinical care. We support the American Medical Directors Association’s (AMDA’s) position on the APN as part of a physician-led collaborative team to provide care for our complex frail elders or the medically complex younger individuals living in our long-term care communities. A recent Perspective article in the New England Journal of Medicine entitled ‘‘Broadening the Scope of Nursing Practice’’ notes evidence from many studies that an APN can, in protocol-driven care settings, provide primary care services such as wellness and prevention, management of uncomplicated acute illness, and management of chronic diseases, such as diabetes, at least as safely and effectively as physicians. It is rare, however, to find patients in long-term care facilities who will meet these criteria. Seniors who reside in our long-term care facilities are usually living there because of complex medical needs that prevent independent living in the community. Although our patients may have a chronic disease, it is often complicated and frequently associated with multiple other active comorbid physical and psychosocial conditions that also require management. Although wellness and prevention are often not priorities for many of these residents, palliation and end-of-life issues often take precedence. Often a practitioner will need to manage acute exacerbations of the chronic disease that may occur before the decision for palliation is made by the resident. These points are made to emphasize the need for a collaboration of health care professionals in the care of our nursing home residents. The physician/APN dyad works particularly well with a focus on the management of acute and chronic illness within an environment that is resource constrained and heavily regulated. In their editorial, Philpot et al highlight the benefits of the APN in facilitating care transitions when the APN is available on site. The APN, however, should not be considered as a substitute for the physician in this context. This is a role that can be fulfilled by a physician actively working with other relevant professionals at each site of care to ensure timely and accurate communication and appropriate follow-up. The medical director of the facility can also facilitate such transitions in the facility through the development and implementation of policies and procedures for the nursing home with the facility interdisciplinary team that