Although NPs can play a valuable role in addressing shortfalls in geriatric care, it may take time for traditional medical settings to take them up on the offer, a new study suggests. ACOVE-2, the second iteration of a model called Assessing Care of Vulnerable Elders, was developed to improve the primary care of geriatric patients using task delegation, notes to guide care, and other resources; the model relies on NPs who can facilitate care management.

Researchers assessed the effectiveness of NP comanagement at two California medical practices from December 2009 to September 2010. The team screened patients 75 years old and older for four conditions: falls, urinary incontinence, dementia, and depression. Over the course of the study, primary care physicians decided case by case whether to refer patients who screened positive for one or more of those conditions to NPs for comanagement; they also had the option of implementing ACOVE-2 interventions without referrals.

The quality of care for patients with falls, urinary incontinence, or dementia who saw an NP was dramatically better than that for patients who saw a physician alone: scores assessing the care of patients with those conditions were 22% to 50% higher with NPs. (Scores regarding care for depression were higher when patients were seen by physicians alone.) But of the 1,084 patients screened, only 49% saw an NP. Of those who did not, 82% lacked referrals from primary care physicians. The authors noted that physicians' unwillingness to delegate care, and possibly skepticism about the value that NPs can offer, may in part explain the low rate of referrals to NP comanagement.

Comanagement isn't easy for some physicians, says the study's lead author, David B. Reuben, chief of the Division of Geriatrics at the David Geffen School of Medicine at the University of California, Los Angeles. "There's a learning curve and trusting curve. At the level of the physician group, you need leadership saying 'this is going to help you.'" Reuben stresses the importance of good communication between NPs and physicians.

Simplifying such processes, as well as working to educate both physicians and patients on the benefits of NP comanagement, may ultimately be the path of least resistance in achieving better patient care.-Laura Wallis

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