PRiMA APN in Primary Health Care

Initial Situation

As part of this project, 1. one APN was deployed in each GP practice in the Bernese Central and Upper (alpine) regions and their contribution was evaluated by means of case analyses, 2. TARMED-relevant services, the contribution to self-management and quality of life in older chronically ill patients, the interfaces and interprofessional collaboration were identified, and 3. recommendations on the legal basis and remuneration of the APN function in Swiss GP practices were drawn up.

Procedure

Multiple case studies were suitable for answering the research questions (Yin, 2018). Thus, both participating GP practices could be included in the study. The respective case was the individual GP practice with the various professionals (doctors, APNs, medical practice assistants, medical practice coordinators, patients, and their relatives), the structural, organisational conditions and processes (such as the physical GP practice or the billing system).

Results

APNs in GP practices work within the GP practice and go on home visits and rounds in old people's homes and nursing homes. They mainly focus on patients with chronic diseases who are in complex, sometimes unstable situations, as well as persons at the end of life. As a result, this group of patients receives treatment more quickly and in a more targeted manner, especially in crisis and emergency situations. Relatives are supported earlier in the process and better involved in the treatment. Due to the APNs, problems are recognized sooner in old people's and nursing homes. Thanks to the APN, health-promoting and preventive measures are introduced more systematically, and patients are supported in their self-management. Overall, evidence-based treatment and care are promoted. Thanks to the combination of in-depth nursing knowledge with medical skills, APNs offer a patient-centred view.

APN and other professionals
 

The cooperation in the family practice changes with the employment of an APN. Management structures need to be adapted to be adequate. But all professionals experience added value, e.g. the flow of information is improved and the medical professionals experience relief. In addition, the connections to other service providers such as home health care organisations or medical specialists are improved. Cooperation with nursing and care professionals, be it in home health care or in old people's and nursing homes, is more successful. These professionals receive further coaching and guidance, which improves their work and enables them to resolve issues more quickly. Currently, APNs look after about half of the patients than the medical specialists.

Legal basis and accounting

In Switzerland, the profession of nurses is regulated by the Federal Law on Health Professions (GesBG). In the Health Insurance Act (KVG), these nursing professionals are also named as service providers, especially concerning the provision of nursing services in Spitex. However, APNs are neither regulated in the GesBG nor authorised in the KVG. As a result, they cannot currently bill the compulsory health insurance (OKP), which is why the use of APNs in GP care is particularly at risk. Interested GP practices must find an interim solution until APNs are recognised as service providers under the KVG. Currently, it is possible to bill mainly via the tariffs for non-physician specialists in TARMED. This possibility will continue to exist in the subsequent TARDOC. In addition, it is possible to bill APN activities for patients at home within the framework of the Health Care Services Ordinance (KLV), in particular Article 7. The prerequisite for this is that APNs are recognised as self-employed nursing professionals or are employed by home health care organisations, for example.
To improve the situation, various cantonal solutions exist to date. Since 2016, the canton of Vaud has supplemented one section in the "Loi 800.01 sur la santé publique (LSP)", namely Art. 124 and 124a to 124bis. With this section, APNs are recognised as service providers who are allowed to treat groups of patients independently. This requires registration with the canton of Vaud. In the canton of Glarus, there is a motion to amend the Public Health Act. The canton also actively promotes innovative projects. Thanks to an agreement, services are reimbursed via a health insurance organisation as well as the canton itself. The Canton of Geneva has included a short section in the Health Act; namely LS K 1 03, Article 85, which determines that medical professionals (unspecified) can delegate certain tasks to APNs, provided they have adequate training. The canton of Neuchâtel is probably interested in APNs in a similar way to the canton of Schwyz. In the latter canton, there is a desirable division of labour between GPs and APNs. Except in the canton of Glarus, questions of billing remain unresolved. With regard to the salary of APNs, the cantonal salary bands apply.

Conclusions

APNs offer added value in family doctor health care. In order to regulate the competences and areas of responsibility, a job description now exists for the canton of Bern. Further research is needed to consolidate these areas of competence and to develop a national consensus. It is also essential to demonstrate the effectiveness of APNs in GP care.

This also requires adjustments to the processes and structures in the respective GP practice. It is apparent that the allocation of patients also needs to be reconsidered. Otherwise, it will be difficult for APNs to develop their own patient base. The connection to a local home health care organisation can be an interesting solution or also the networking with local elderly people's and nursing homes.
At present, APN services are not adequately remunerated. For this, APNs must be recognised as service providers under the HIA. This means that the total costs associated with APNs must be presented and other aspects such as effectiveness, appropriateness and economic efficiency must be shown. In any case, it is urgent that APNs are regulated at the legal level in order to pave the way for a billing option.