The relationships I have fostered with my patients as a geriatric nurse practitioner have been invaluable, and I see this as time well spent and making a true impact on their quality of life. I am also able to advocate for my patients as they work with their primary care provider and specialists, as well as other members of the healthcare team. I am able to collaborate with ancillary staff such as physical therapy, mental health, dieticians, case workers and care managers to better coordinate patient care and achieve positive outcomes, both large and small.
About Renee Reed, ANP-C, GNP-BC, MSN, RN, LNCC: Renee Reed is an Adult-Gerontologic Nurse Practitioner (AGNP) at Landmark Health, where she provides around-the-clock in-home primary care services to geriatric patients suffering from chronic and debilitating diseases. Prior to working at Landmark Health, Ms. Reed worked as an AGNP for Avamere Health Services, providing long-term sub-acute health care to elderly patients in a nursing home care environment, and as an AGNP for United Healthcare/Optum Health, managing the primary care of nursing home residents across three different nursing homes in the Portland, Oregon area. Ms. Reed also worked for over a decade as a critical care Staff Nurse at Oregon Health & Science University in Portland, caring for acutely ill patients across multiple critical care units, including neurosurgical, trauma, and cardiac-surgical ICU. During her time as a Staff Nurse, Ms. Reed served as a Legal Nurse Consultant for Eclipse Legal Nurse Consulting, LLC, conducting literature reviews and research, malpractice case screenings, and medical record reviews. Ms. Reed is dual-board certified as both an adult and geriatric nurse practitioner through the American Nurses Credentialing Center (ANCC).
Ms. Reed earned her Master of Science in Nursing from the University of Phoenix in 2005 and her Bachelor’s of Science Degree in Nursing from Oregon Health and Science University in 1996. She also earned her Post-Master’s Certificate in Advanced Practice Nursing at the University of Massachusetts Boston in 2011, where she completed dual adult and geriatric nurse practitioner tracks.
[OnlineFNPPrograms.com] Could you please describe the path you took to train yourself for your current field of advanced practice nursing?
[Renee Reed, ANP-C, GNP-BC] I started undergraduate studies at the University of Oregon, with pre-medicine and psychology courses. I then returned home, and completed basic college courses with a focus in emergency medical technology and pre-nursing. I couldn’t afford a four year college at that time. I graduated in 1992 with an Associate of Applied Science Degree from Umpqua Community College and an Occupational Minor in Emergency Medical Technology. During that timeframe, I completed my pre-nursing courses and was accepted into Oregon Health & Science University’s School of Nursing at Southern Oregon University in 1994. I spent much of my undergraduate educational years working part-time as a hospital unit clerk, ER technician, an EMT/paramedic.
I graduated with high honors from OHSU with a Baccalaureate in Nursing in 1996. I took a job as a new grad RN a few months later, directly into the critical care units at Rogue Valley Medical Center. I worked there until 1997, and decided to take a job at Oregon Health & Science University in Portland, in the cardiac medical intensive care unit. I worked there as a critical care RN/charge nurse for nearly 12 years, caring for the some of the sickest patients in Oregon; I floated from the CMICU to other critical care units, including trauma, neurosurgical, and cardiac-surgical ICU. I served on our bargaining unit’s grievance, contract negotiation, and executive committees. We went through the OHSU nurses’ strike in 2001, and I left OHSU in 2007. In that timeframe, I graduated from the University of Phoenix with my Master’s in Nursing in 2005. I had also completed my legal nurse consulting certification through Kaplan, and had been working part-time off and on as a legal nurse consultant for a few attorneys in the Portland area. I worked on both plaintiff, defense, and medical settlement cases.
Not quite ready to jump to advanced practice, I decided to take a job with Legacy Health/Legacy Meridian Park Medical Center for a “slower” paced ICU; there, I worked as a critical care and relief charge nurse as I started the nurse practitioner dual track program at University of Massachusetts Boston. I was their first online student from Oregon. While taking didactic courses through UMASS, I did my clinical rotations at various locations in the Portland Metro area. I also did part-time work through Advantage Nurse Staffing (a temp agency). During my agency shifts, I took shifts at the Kaiser Permanente urgent care clinic and regional telephonic advice center in Portland. I also worked some shifts at Vibra, the long-term acute care hospital (LTACH) in Portland. I graduated with honors from University of Massachusetts Boston in 2011, and later achieved dual-board certifications as both an adult and geriatric NP.
[OnlineFNPPrograms.com] Could you please describe your role and responsibilities as an Adult/Geriatric Nurse Practitioner at Landmark Health? What kinds of medical conditions and challenges do your patients face, and how do you help them manage their conditions?
[Renee Reed, ANP-C, GNP-BC] Landmark Health is a new, innovative program/company that launched in 2013 in New York State. Landmark partners with health insurance companies, and here, in Oregon, we are partnered with Healthnet Medicare Advantage patients that qualify for Landmark’s at-home chronic disease management program. Healthnet has identified these patients as meeting specific criteria of six or more chronic conditions. These conditions include six or more of the following: atrial fibrillation, congestive heart failure, dementia, depression, peripheral vascular disease, hypertension, chronic kidney disease, cancer, coronary artery disease, and cerebral vascular disease.
The goal of this care model is to manage chronic diseases and keep patients at home for as long as possible, and to get ahead of those triggers that send them to the hospital and emergency room. As an adult/geriatric nurse practitioner, I deliver care to these patients in their home environment, 24 hours a day, seven days a week, day or night, including holidays. We rotate our call coverage amongst providers. It is essentially a concierge medical model, for those patients who can’t exactly afford concierge medicine, but truly benefit from it. At Landmark, our providers (MD, NP, PA) are considered Complexivists™; we work with a Complexivist™ interdisciplinary team that includes social workers, nurse (RN) case managers, case manager assistants, mental health nurses and nurse practitioners, dieticians, pharmacists, and a management team that includes an on-call psychiatrist, regional medical director, clinical integration officer, health services advisors, community outreach representatives, and IT specialists that are currently helping us to build our very own EMR program with clinician guidance.
On a typical day, we will respond to urgent visits in the patients’ home as well as manage and coordinate preventative care with their primary care providers and specialists. We typically see patients urgently for symptoms of infection, and can initiate IV fluids and antibiotics in the home if needed to “get ahead” of infections that may become worse and turn into an Emergency Department visit or admission to the hospital. We also can draw labs in the home, and have results without having to go to an actual lab. Our providers will, with the assistance of nurse case managers, assist our patients with making appointments, arranging transportation, and working with their health plan to clarify benefits. Another typical daily activity we do in the home is assist patients with their medications. We do periodic medication reconciliation to see if we can reduce and optimize their medication regimen.
We, as a provider team, hold weekly Interdisciplinary Team (IDT) meetings where we each review our previous week’s visits, discuss those cases that have resulted in sentinel events (hospitalizations, ED visits, etc), and review where we may have had more of an impact in avoiding these admissions. Sometimes, we can’t. Sometimes, it’s a process issue. And because our patients are chronically ill and complex, we all benefit from discussing the cases and seeking input from the various team members, from mental health providers to our case workers. This helps us to make adjustments to the patients’ plan of care. We also are able to collaborate on clinical pearls and educate each other on various topics. For example, a few of our clinicians are somewhat new to the older geriatric population; those of us who have a lot of experience with geriatrics impart our experiences and education to give them an edge in working with this population.
[OnlineFNPPrograms.com] You also worked as an Adult-Geriatric Nurse Practitioner for United Healthcare/Optum Health, specifically with dual-eligible Medicare and Medicaid patients in a long-term post-acute care setting, and as a Adult-Gerontologic Nurse Practitioner for NP2U/Avamere Family of Companies. Could you describe in detail what your daily and long-term responsibilities were in these roles, and in what ways this position was different from your current role as an in-home nurse practitioner?
[Renee Reed, ANP-C, GNP-BC] Daily responsibilities in my role with UHC/Optum were quite similar to my current role, only in the long-term care and post-acute/skilled setting. I was assigned dual-eligible patients between three different nursing homes in East Portland. Many of these patients have multiple chronic diseases, including dementia, multiple sclerosis, paraplegia, congestive heart failure, severe depression, immobility, chronic kidney disease, and diabetes. These patients had more mental health challenges as well, and we frequently managed their depression, anxiety, and PTSD, for example. They were also of lower socioeconomic status and required a lot of care coordination. This position was different in that it was strictly regulated by the Centers for Medicare and Medicaid Services (CMS) and nursing home regulations. This role entailed working with patients with much higher needs with regard to socioeconomic issues. Their medical problems were quite challenging to manage. They were also high utilizers of the emergency room and had higher hospitalization rates. They required frequent visits and monitoring to help reduce the number of hospital readmissions. These patients were perhaps the most rewarding to assist; they desperately needed more monitoring and attention, and “touches” from a provider. Throughout my day, I would respond to urgent calls, and we also covered these patients telephonically in the off hours, helping nursing home staff coordinate their care. I would diagnose, treat, and write orders for interventions and medications.
NP2U is a relatively young in-house midlevel primary care provider program. I worked at NP2U/Avamere Family of Companies for four months, and was based in a long-term nursing home that did not only long-term nursing home care, but also rehabilitation/skilled nursing care for post-acute elderly/adult patients. I worked along with the nursing home team, with everyone from the medical records department, nursing staff, dietary staff, and nursing administration, to the director of nursing addressing acute and chronic issues with the nursing home residents. I worked directly with the nursing home’s medical director (physician). I would diagnose, treat, and manage acute and chronic conditions. This would include writing orders for interventions, treatments, and prescribing medications.
I would also assist residents, their families, and nursing staff with palliative care and advanced care planning. I would assist in transferring patients to Hospice programs, and prepare the patients to discharge to home. I would also provide inservices and training to the nursing home staff (intravenous therapy, clysis therapy, medication education, etc.). We used our own EMR, as well as the nursing home’s EMR. I was based in the nursing home to be available for acute issues as they would arise. The over-arching goal of this program was to increase the quality of care to nursing home residents and skilled patients, to reduce readmissions to the hospital, and decrease transfers to the emergency room.
[OnlineFNPPrograms.com] Why did you decide to become an adult-geriatric nurse practitioner, and what professional experiences helped you determine that this area of advanced practice nursing was the right one for you?
[Renee Reed, ANP-C, GNP-BC] Professionally, as I worked as a critical care nurse, I saw the greatest need with geriatrics. The majority of these patients who were critically ill were 65 and older. Many had not discussed advance directives with their families, and ended up getting many interventions that they really did not want. Advanced care planning was a need I saw that was relevant to everyone, but particularly for this patient population. I also saw that elderly patients had many issues that were not managed appropriately, or they did not have enough primary care involvement and management. I also, in general, witnessed the medical community overlook them and not see them as a priority. I grew interested in ways to help advocate for these older patients and help them manage their chronic issues and socioeconomic needs. Many wanted to refill their prescriptions, but could not afford them on a fixed income. Some wanted to have limited interventions, but their family wanted them to have more interventions than they were comfortable with.
In other cases, elderly patients’ primary care providers wanted to have them come in for check-ups, but they did not drive or had to use public transportation, or their mobility was limited or required the use of a walker, etc. Some would be admitted to the hospital on over thirty medications; how does that happen? I wondered how we as a society and medical community could be more proactive and involved in avoiding catastrophic illnesses later in life, and better at managing elderly patients’ care. How could we help to bridge these gaps in providing care? These patients are also very complex and challenging; many providers get overwhelmed managing so many conditions, and only have 10-15 minutes to spend with these patients. It’s not enough. And I love puzzles. I love challenges.
And most of all, I got the most enjoyment from geriatric patients. They have experienced so much in their lives, and have incredible journeys to share. When Landmark’s model came around, I knew immediately that this was my place. This was the answer. Instead of having frail, elderly, chronically ill patients trying to come IN for appointments, and helping to address the gaps in getting them their care, we could extend our services to them in the community, like we used to do; house calls. Doctors used to go TO their patients. With this patient population, it makes perfect sense. And it provides a great sense of relief to these vulnerable patients to have a provider they can reach out to 24/7 if they have issues and can’t get in to see their primary care provider, or worry about cost. Landmark’s visits cost nothing to them. It is a different model as far as payment goes.
Their model also attracted me to work for them. I am able to see my patients in their home as often as needed, for as long as needed. Some of my visits are as long as 90 minutes. This enables me to sit down with them, take my time with them when it comes to educating them on their illnesses and medications; I also spend time with their families and get a glimpse of their life. You can tell a lot about a person from their living situation. Many clues abound there that you wouldn’t necessarily see when they come in for a visit. Having patients show me how they manage their medications, or prepare their meals, or get their groceries (or even what is in their fridge!) helps me to help them manage their illnesses better. This in turn improves their quality of life, decreases acute issues and hopefully visits to the ED/hospital. This can even extend their time in their home, rather than landing in a nursing home after a catastrophic illness and never being able to go home. I don’t take the place of their primary care provider, but rather act as an extension of primary care in the patients’ homes. I am able to complete the same responsibilities as the primary care provider: diagnose, treat, and write prescriptions and interventions such as home health or referrals to certain services. This helps to streamline patient care and fill those gaps.
Personally, I pursued a career in geriatrics after experiencing my Grandmother’s dementia. I knew so little about the disease back then, and there was so much that I had learned from caring for her in her last few months. Seeing how the medical community interacted with her, and how she lost her independence was difficult. She was an incredibly strong, independent woman who declined into such a shell of who she once was. She refused to talk about advance directives when she was younger, and my family didn’t know how to assist with this. My Grandmother and I were very close; she was the matriarch of our family and she was an important role model for me. She still teaches me things to this day; I remember pieces of advice she gave me, and how she handled adversity and change. She was so strong. I only wished we could have given her more dignity and honor in her death. My work is how I honor her.
[OnlineFNPPrograms.com] What have been some of the most rewarding aspects of working as an adult-geriatric nurse practitioner, both in a long-term care facility and in in-home settings? On the other hand, what specific challenges have you encountered in this field of work, and how have you managed these challenges?
[Renee Reed, ANP-C, GNP-BC] Most rewarding aspects: many. I am able to spend time with patients who desperately need it, both medically and emotionally. The relationships I have fostered with my patients as a geriatric nurse practitioner have been invaluable, and I see this as time well spent and making a true impact on their quality of life. I am also able to advocate for my patients as they work with their primary care provider and specialists, as well as other members of the healthcare team. I am able to collaborate with ancillary staff such as physical therapy, mental health, dieticians, case workers and care managers to better coordinate patient care and achieve positive outcomes, both large and small. I am able to advocate a patient’s wishes at end-of-life, and help them to die with dignity and as they wish, not how others feel they should. That is rewarding. I am also able to give back a bit to the nursing staff through education and support.
Working a job in any aspect of long-term care is demanding, stressful, and difficult. The long-term care team oftentimes is overworked, underappreciated, and poorly understood. While I was incredibly busy with patient care, I made every effort to be supportive of the nursing home staff, and spent time with them through education and just getting to know them. That goes such a long way in this work environment.
Specific Challenges: our broken healthcare system in general. Care is very fragmented for these chronically ill geriatric patients, particularly in the nursing home setting. Trying to coordinate between specialists and primary care physicians who may or may not appreciate your involvement creates roadblocks for these patients. They have the final say and when they disagree with my perspective or are unwilling to make adjustments, it’s disheartening. Waiting for return phone calls, trying to obtain good medical records, particularly if they had just come from the hospital, can be difficult. Family conflict and disagreements can also be challenging. Wanting everything done for a patient that is 95 with terminal cancer is difficult for everyone involved, and having people understand that despite modern medicine, not everyone has good outcomes and no one lives forever. Other challenges include financial challenges for patients. My veteran patients will wait months for appointments; obtaining their records is daunting. Just ordering a walker, or in-home care for patients discharging from care homes can be like climbing Mount Everest. Some days you want to go buy a bedside commode personally to avoid the red tape that comes with submitting it to insurance or Medicare. There may be a perfect medication for a patient but due to cost, it’s not truly an option. I’ll never understand why a narcotic is covered, yet a lidocaine patch is not, for example. The challenges basically stem from a very broken system.
For students considering long-term care and geriatrics. I recommend a good solid 2-5 years of acute care experience as an inpatient nurse. Critical thinking skills are a must. I would recommend a clinical rotation in a long-term care or home care setting as well. Get a well-rounded experience when it comes to clinical time in school. I did this as an NP. I patched my clinical hours together in orthopedics (trauma, osteoporosis and fractures, hip replacements, etc.), ophthalmology (glaucoma, macular degeneration, retinopathies), oncology (cancer, especially prostate, breast, and ovarian cancer), memory care units (dementia; a strong understanding of it and how to manage and interact with patients with dementia is crucial), and a mental health rotation with a therapist or inpatient ward. Well-rounded.
[OnlineFNPPrograms.com] For current and prospective MSN students who are interested in becoming adult-geriatric nurse practitioners, what advice can you give them about optimally preparing for this field while pursuing their degree?
[Renee Reed, ANP-C, GNP-BC] I would refer back to the previous answer. MSN students should have at least 2-5 good solid acute care years under their belt. A solid understanding of chronic illness and pathophysiology is a must. While I feel I have a fairly good grasp, I am still going back for more reviews and to better understand advanced pathophysiology and the managing of multiple chronic illnesses. Our provider team has weekly meetings and share complex cases; this helps me to better understand and learn how to navigate these patients and their issues.
A very well-rounded clinical rotation is recommended. I struggled to patch together a long-term internship as an NP student. This was a mixed blessing. I got creative and did shorter rotations in several different areas that are commonly seen with geriatrics: oncology, ophthalmology, dermatology, urology, orthopedics, rheumatology, hospice, diabetes management and education, and long-term care. I would strongly recommend a part-time job in a nursing home, as a medication aide, nurse assistant, or care manager. Doing many areas helped me to prepare for the issues I see in geriatrics daily.
I would recommend shadowing a nurse case manager or discharge planner. Geriatric patients, when discharged from the hospital, sometimes don’t go back home; they are placed in a higher level of care, and that is their new home. Witnessing this process and the barriers that patients undergo, and the dramatic life changes it means to them, is eye-opening. Clinical hours with an already-practicing geriatric NP, PA, or MD is invaluable. Aligning yourself with professional organizations such as the Gerontological Advanced Practice Nurses Association (GAPNA) is helpful. Here in Oregon, we have the Oregon Geriatric Society. Both have annual conferences to attend. I would also familiarize oneself with state organizations such as Aging and Disability, and become very familiar with CMS and Medicare regulations. Nursing homes are very heavily regulated. Understanding these regulations will be helpful as well. I would also try to take a strong pharmacology course, specifically those geared toward geriatrics are a must. There is a list of medications to avoid when treating the elderly–The Beers List. This should be something every nursing and medical professional should know well. Palliative care courses and internships would be helpful as well. I would recommend reading Atul Gawande’s book Being Mortal: Medicine and What Matters in the End. All medical and nursing students should read this book. Goals of care is an area in which the medical community as well as patients (which is everyone!) need to be better informed. Many students who rounded with me had a hard time understanding that “comfort care” did not mean no care. This book helps explain why sometimes doing less, is more when it comes to medical innovation. Sometimes doing more is keeping patients comfortable, and letting them decide to say no to treatments and interventions. It’s a complex ethical issue that medical and nursing students need to better understand.
Thank you Ms. Reed for participating in our APRN career guide interview series!