The American Academy of Physical Medicine and Rehabilitation was approved as a medical specialty in 1947 by the Advisory Board of Medical Specialties.1 Physical Medicine and Rehabilitation (PM&R), also known as physiatry, emphasizes prevention, diagnosis, and treatment of patients who experience limitations in function due to any disease process, injury, or symptom. PM&R multidisciplinary teams work together to achieve patient-centered goals that are aimed at restoring the optimal, or prior, level of functioning.
Members of the physiatry team may include the physiatrist or physician, nurse practitioner (NP), physical therapist, occupational therapist, speech therapist, respiratory therapist, nursing staff, social worker, and others. By blending the best of the traditional medical approach (which adds years to life) with the functional model (which adds life to years), the PM&R team enhances and restores functional ability and quality of life to those with physical impairments or disabilities.2
A study funded by the Medicare Payment Advisory Commission found that patients in a skilled nursing facility with hip or knee replacements are significantly older and have more comorbidities and complications compared with inpatient rehab facility patients.3 With more patients being discharged from acute care to skilled nursing facilities (SNFs), the combination of medical and functional knowledge and expertise of a multidisciplinary team will enable the SNF patient in need of rehabilitation to achieve the highest functional outcome at the least financial cost to our society.2
Role of NPs in PM&R
The nature of the PM&R practice requires skills in interpersonal communication, multisystem diagnostics, mechanical interventions, and therapeutic modalities.
The Association of Rehabilitation Nurses (ARN) Standards and Scope of Practice defines advanced practice rehabilitation nursing as the integration of clinical practice, education, research, leadership, and consultation, all of which require intraprofessional and interprofessional collaboration.4
NPs in the rehabilitation setting possess and demonstrate advanced levels of expertise in providing, directing, managing, and influencing the care of rehabilitation patients.4 NPs also provide clinical expertise in supporting the functions of other healthcare providers.
Close communication with the primary attending service is essential for high quality patient care. The NP will monitor the medical status of the patient as well as the patient’s functional status to determine progress toward goals, and the NP will identify and record any barriers to reaching functional goals. NPs in PM&R may also provide medical services such as treatment of spasticity or pain that is limiting functional gains. The NP may make recommendations for further medical evaluation and treatment. The NP can identify and prescribe adaptive or assistive devices for safety and to further facilitate function (Table).2
Table. Role of the Nurse Practitioner in PM&R4,5
|Review appropriateness and effectiveness of therapy||Functional assessment||Staff education|
|Identify barriers to treatment||Pain management||Patient education|
|Set functional goals||Cognitive and mental health assessment||Knowledge of pathology & pathophysiology of diseases & trauma|
|Minimize hospital readmissions||Assessment of bowel and bladder function||Implementation and evaluation of clinical and operational protocols|
|Manage medical & other complications related to the rehab diagnosis||Sleep assessment and management||Counsels patients and families|
|Provide discharge planning and education||Early recognition of status changes that could hamper rehab (ie–UTIs)||Serve as a client advocate|
|Development of clinical guidelines, policies and procedures||Use of evidence-based models to restore function||Act as a mentor to nurses and students|
|Incorporates relevant research findings into practice||Provide documentation to facilities and payor agencies||Provide continuing education programs|
|Evaluate and coordinate the multidisciplinary care program||Evaluate clinial outcomes||Evaluates data to promote optimal rehabilitation outcomes|
The role of the NP is a valuable asset within the rehabilitation setting. The value can be measured by the improved cost effectiveness of patient care, increased nursing staff clinical knowledge and skill, reduced frequency of complications for the rehabilitation patient, increased quality of nursing care, development of new knowledge and innovations, and savings on expenses resulting from the availability of a clinical expert for consultation services.4 In one study, NPs were found to provide efficacious care to people with disabilities, resulting in cost savings, improved outcomes, and high value.5
Legislative Impact on NP Role in PM&R
The Improving Medicare Post-Acute Care Transformation (IMPACT) Act was signed into law on October 6, 2014.6 IMPACT was created to improve the quality of care for patients in rehabilitation, home health care, nursing home, and long-term care. The Act standardized the reporting of quality measures such as functional status, cognitive function, and changes in function and cognitive function. IMPACT also standardized reporting of potentially preventable hospital readmissions rates, incidence of major falls, changes in skin integrity, and discharge status.6
The NP in PM&R can directly impact all of those quality measures. The use of standardized quality measures and standardized data allows the provider to coordinate care, improve outcomes, and complete quality comparisons.6
The Office of the Secretary, Department of Defense announced in 2010 that TRICARE, the US military health plan, will allow NPs to issue referrals to patients for physical therapy, occupational therapy, and speech therapy without requiring the patient to see a physician.7 The ruling was made in alignment with Medicare’s allowance of nonphysician providers (such as NPs) to provide, certify, or supervise therapy services as a result of the 1997 Balanced Budget Act which expanded Medicare coverage of NP services.7
Benefit of MPs in PM&R
NPs can have a measurable impact on clinical productivity.5,8 In a study of 206 PAs/NPs in outpatient National Comprehensive Cancer Network-oncology services, the authors concluded that “given the increasing complexity of oncologic care and the increased population of patients with cancer and cancer survivors requiring that care, PAs/NPs have the potential to fill important roles in both outpatient and inpatient care settings.”8
Multi-disciplinary, team-based care is at the core of PM&R practice. Today’s health care landscape requires the team-focused model to achieve a satisfying patient experience, improve population health, reduce costs, and improve the work life of clinicians and staff.9 Payors are moving to value-based care programs, which puts further emphasis on meeting high quality standards.9 NPs have a positive impact on practice activities and staff assessment skills in the SNF setting.10 NPs can significantly impact the care in long-term care facilities.10 The NP can provide a positive impact on the continuity of care, with comprehensive documentation, oversight of the appropriate use of specialized services, and timely access to medical care.10 NPs are effective and add value to collaborative chronic disease management.11 Because of differences in professional experiences and educational background, NPs have much to offer as a member of a multidisciplinary PM&R team at a time when high quality health care, documentable outcomes, and affordable costs are increasingly under scrutiny.11
Denise Goddard, DNP, MSN, RN, FNP-C, currently teaches in the Graduate Master of Science in Nursing program at Angelo State University. She also maintains a clinical practice in physiatry in the Dallas-Ft Worth, Texas area.
- American Association of Physical Medicine and Rehabilitation. History of the specialty. https://www.aapmr.org/about-physiatry/history-of-the-specialty. Accessed June 25, 2020.
- American Association of Physical Medicine and Rehabilitation. Physiatrists Role in Skilled Nursing Facilities. https://www.aapmr.org/docs/default-source/protected-advocacy/Position-Statements/snf_positionstatement_fnl.pdf?sfvrsn=0. June 29, 2016. Accessed June 25, 2020.
- Medicare Payment Advisory Commission. Report to the Congress; Issues in a Modernized Medicare Program, 108 (June 2005). http://22.214.171.124/documents/June05_Entire_report.pdf. Accessed June 30, 2020.
- Association of Rehabilitation Nurses. What does an Advanced Practice Rehabilitation Nurse Do? https://rehabnurse.org/about/roles/advanced-practice-rehab-nurse. Accessed June 25, 2020.
- Kosevich G, Leinfelder A, Sandin KJ, et al. Nurse practitioners in medical rehabilitation settings: a description of practice roles and patterns. J Am Assoc Nurse Pract. 2014;26(4):194-201.
- AMDA – The Society for Post-Acute and Long-Term Care Medicine. IMPACT Act of 2014. https://paltc.org/impact-act-2014. Accessed June 25, 2020.
- Office of the Secretary, Department of Defense. TRICARE: non-physician referrals for physical therapy, occupational therapy, and speech therapy. Final rule. Fed Regist. 2010;75(159):50880-2.
- Hinkel JM, Vandergrift JL, Perkel SJ, Waldinger MB, Levy W, Stewart FM. Practice and productivity of physician assistants and nurse practitioners in outpatient oncology clinics at National Comprehensive Cancer Network institutions. J Oncol Pract. 2010;6(4):182-187.
- American Association of Physical Medicine and Rehabilitation. The Role of the Advance Practice Provider in Rehabilitation Care. https://www.aapmr.org/docs/default-source/default-document-library/advancedpracticeprovider_aapmrpositionstatement_0618.pdf?sfvrsn=0. Accessed June 25, 2020.
- Kaasalainen S, DiCenso A, Donald FC, Staples E. Optimizing the role of the nurse practitioner to improve pain management in long-term care. Can J Nur Res. 2007;39(2):14-31.
- Litaker D, Mion L, Planavsky L, Kippes C, Mehta N, Frolkis J. Physician-nurse practitioner teams in chronic disease management: the impact on costs, clinical effectiveness, and patients’ perception of care. J Interprof Care. 2003:17(3):223-237.