Op-Ed: Exploring the Role of Physician Assistants and Nurse Practitioners in Long-Term Care
In order to meet needs of a growing population, including seniors, the BC government needs to look at new care models including introduction of new health professionals. Michael Kary, Director of Policy and Research provides an overview of two such health professions – nurse practitioners and physician assistants – that could warrant further consideration in our health care system, particularly within the continuing care sector.
Op-Ed: Exploring the Role of Physician Assistants and Nurse Practitioners in Long-Term Care
On a regular basis, the media has highlighted the current shortage of physicians as well as the growing population, including seniors, without a family doctor. This has led the BC government to establish programs such as ‘GP for Me’, a jointly funded initiative with the government and the Doctors of BC to increase overall access to general practitioners (GPs).
While such initiatives including increasing the number of GPs may be part of the solution, it will also be important to look at new multidisciplinary models including the role of new care providers, particularly in the growing continuing care sector. A couple of examples that warrant further consideration are that of Nurse Practitioners (NPs) and Physician Assistants (PAs).
With respect to NPs, a UK study estimates that they could perform about 20% of the work currently undertaken by GPs. Since 2005, BC began graduating and regulating NPs, with about 45 students per year. Overall, progress in implementing NPs has lagged behind other provinces including Ontario and Alberta. One of the major problems has been that insufficient funding has left many NPs unable to obtain employment. Although in 2012 the BC government announced $22.2 million to pay for 190 positions over the next three years, it is not clear whether some commitments will continue in the future. As of January 2014 there were only 287 NPs registered in BC. Another survey also shows that less than 10% NPs who responded (8% or 7 in total) identified residential care as a practice setting.
While the role of NPs needs to be further supported, one health profession that should also be explored further, particularly within the long-term care setting is that of physician assistants (PAs). PAs are essentially healthcare professionals educated in the medical model to practice medicine under the direction of a physician. In a formal practice arrangement with a physician, PAs practice medicine which includes obtaining medical histories and performing physical exams, ordering and interpreting laboratory and diagnostic tests, providing therapeutic procedures, prescribing medications, and educating and counselling patients.
Recent studies have highlighted the benefits of PAs including that they can increase access to medical care for seniors. In particular, having a full-time PA on staff at a nursing home or long-term care facility can translate into patients being evaluated sooner and can prevent transfers to the hospital in many cases. A study from the United States, shows that PAs in long-term care settings have decreased hospital admission rates by 38% for seniors. PAs can also have an important preventive role in the care of geriatric patients.
According to a 2015 policy paper from the British Columbia Ministry of Health, two ways to further implement PAs into the health care system would be: role substitution, by substituting one health care professional for another in order to provide a service and role delegation by delegating specific tasks from one professional to another, set out through an authority or legislation.
Provided the necessary training and quality checks are in place, PAs may be able to provide substitute services traditionally performed by other healthcare professionals. Role substitution, for example, can benefit both the patient and health service provider, by allowing healthcare dollars to be reallocated to other priority areas. The BC Ministry of Health estimates that 25 to 70 per cent of general practitioner tasks could be delegated to other health service providers. By delegating specific roles or responsibilities to PAs, other health care professionals could have more time to provide services elsewhere. The use of role substitution and role delegation to expand the role of PAs into the health-care sector could be useful also in freeing up healthcare dollars and decreasing the workload of other industry professionals.
A 2014 study by Nanos Research shows overwhelming support for a rapid expansion of PAs into Canada’s health care system. The study of 1,000 Canadians released at the Canadian Association of Physician Assistants’ (CAPA) Annual Conference in Halifax last year, reveals that about 80% of Canadians are supportive of PAs having a greater role in providing health care and are comfortable receiving care from a PA in Canada. Support for PAs was strongest amongst Canadian seniors of whom almost 9 in 10 supported an expansion of PAs. The positive results led the President of CAPA, Chris Rhule, to call for immediate action to introduce PAs in those provinces, including British Columbia, which has not yet taken advantage of the high level of care provided by these professionals.
While relatively new in the Canadian health care setting, PAs have been practicing in the Canadian Armed Forces for over 50 years and have been instrumental in providing a high level of care to soldiers on the front lines. PAs also practice in a variety of specialties including emergency rooms, primary care, orthopedics, psychiatry, and neurosurgery in a number of provinces including Alberta, Manitoba, Ontario and New Brunswick. 
Studies from the United States where 95,000 PAs are practicing, demonstrate that PAs can maximize service for patients while helping the health care system to reduce spending and have been shown to decrease the hospital admission rates by 38% for seniors.
The BCCPA would like to explore further what role PAs as well as NPs can play in the health system, particularly within the long-term care setting to help improve health outcomes for seniors, reduce emergency visits and potentially decrease the burden faced by care aides and nurses. In this regard, the BCCPA is considering hosting a future Care to Chat panel event on this important topic and other human resource related issues in the continuing care sector.
 Vancouver suffers shortage of family doctors. Vancouver Sun. Pamela Fayerman. February 19, 2014. Accessed at: http://www.vancouversun.com/health/Vancouver+suffers+shortage+family+doctors/9527604/story.html
 Ministry of Health. Primary and Community Care Policy Paper. February 2015. Accessed at: http://www.health.gov.bc.ca/library/publications/year/2015/primary-and-community-care-policy-paper.pdf
 In BC a NP is a Registered Nurse with a Master’s Degree, advanced knowledge and skills who provides health care services. NPs are able to diagnose, consult, order interpret tests, prescribe, and treat health conditions. They also work independently and collaboratively to provide British Columbians with Primary and Specialized Health Care using a team-based approach.
 Are nurse practitioners the cure for B.C.’s family doctor shortage? Globe and Mail. Rod Mickelburgh. January 5, 2013. Accessed at http://www.theglobeandmail.com/news/british-columbia/are-nurse-practitioners-the-cure-for-bcs-family-doctor-shortage/article6970838/
 BC funds more Nurse Practitioner positions. Ministry of Health media release. May 31, 2012. Accessed at: http://www.newsroom.gov.bc.ca/2012/05/bc-funds-more-nurse-practitioner-positions.html
 A Survey of Nurse Practitioner Practice Patterns in British Columbia. University of Victoria and Michael Smith Foundation for Health Research. January 2014. Accessed at: http://www.uvic.ca/research/projects/nursepractitioners/assets/docs/NP%20Practice%20Patterns%20Report.pdf
 Although educated and qualified as generalists, PAs receive additional education, training, and experience on the job and may work in primary care or specialty areas in a wide variety of practice settings. University of Manitoba. What is a Physician Assistant? Accessed at: http://umanitoba.ca/faculties/health_sciences/medicine/education/paep/whatisapa.html
 Hooker, Cawley and Asprey. (2010). Physician Assistant Specialization: Nonprimary care. PA Specialty Care. Ch. 7. p.p. 235. Accessed at: http://capa-acam.ca/wp-content/uploads/2013/09/PA-FACT-SHEET-2013_FINALcopy.pdf
 Cross Sector Policy Discussion Paper (2015) “Enabling effective, quality population and patient-centred care: A provincial strategy for health human resources”. BC Ministry of Health.
 Physician Assistants Summary Project. CAPA. October 2014. Accessed at: http://www.nanosresearch.com/library/polls/POLNAT-S14-T623.pdf
 CAPA. New Study Shows Canadians Want Physician Assistants to Play a Greater Role in Their Health Care. October 24, 2014. Accessed at: http://www.newswire.ca/en/story/1433470/new-study-shows-canadians-want-physician-assistants-to-play-a-greater-role-in-their-health-care.
 Hooker, Cawley and Asprey. (2010). Physician Assistant Specialization: Nonprimary care. PA Specialty Care. Ch. 7. p.p. 235.