1lovingmom Asked August 2017
What is a physician assistant's scope of practice?
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My mom is being seen by a PA at the facility where she lives. Recently she was diagnosed with heart failure by a cardiologist. The PA convinced my sister to cancel moms next cardiology appointment because the PA stated, "they just want the money and he has worked with cardiologists in the past and knows how to take care of my moms heart needs." Is this PA overstepping his scope of practice? I was able to reschedule the cardiology appointment but my sister still thinks this PA can handle moms heart failure. I personally absolutely do not agree.
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Practices on a consulting basis to an AL facility, or practices that work out of rehab facilities, do NOT have access to that kind of history, and in my experience have NEVER asked me to provide it. They draw their own conclusions, on a short term basis and based on data from the hospital. That doesn't always reflect a longer term condition, which should be factored in.
The 2nd PA was in my back surgeon's office. New to the job, and I asked for a refill of pain pills, 5 days post op. Totally normal, since I was discharged with a very strong pain reliever and needed something less sedating. He said "After 5 days, you shouldn't have ANY pain". I reminded him that after my first surgery I was on Vicodin for 6 weeks. This was 5 days. Said, "The dr fixed what hurt. Just take Tylenol". Wasn't going to fight him. I left, talked to the front office and made a complaint and went straight to my PCP who treated my pain with the lower dose of Norco.
Good thing I went with my gut feeling. PA's can be very, very good at dxing the regular small stuff, and this PA should have been more in tune and sensitive, but sometimes they just aren't very good. Just like drs. They do take a great load off the drs backs as they are all overwhelmed and a good PA can lighten that load.
Also, PA's work is ALL reviewed by the dr in charge. The dr will catch the "heat" first, for the PA's decisions.
You have to speak up, though. If you are unhappy with the care, tell someone, or fill out the survey forms online that they're always pushing.
In another thread you wrote that the place your mom is in - which seems to be an AL - has an outside medical group under contract to provide care & this PA works for this group. So PA not staff at the facility, right? If so, he's under umbrella of the medical group. Not employee of the AL so not actually under purview of the DON. And absolutely not under purview of the cardiologist.
It's obvious that your unhappy with moms care & theres communication issues all around and to add to this you & your 2? siblings are coDPOAs...... But it could well be that mom is way way WAY beyond the level of care that an AL should provide. ALs expect them to be fully functioning on their own with their ADLs with somewhat minimal assistance. If mom cannot dress, walk, eat, do basic hygiene & meds on her own, either she needs to pay for aides, have medication management added or move to a facility that provides for a higher level of care as she cannot do on her own.
I'd suggest that asap whomever is the main dpoa of you 3 for finances & medical schedule a care plan meeting for next week at the AL. If it's that mom now needs a higher level of care, then all need to know what level of care asap and if this AL cannot do it then you go & find a new facility. Ask that cardiologist where he would place his mother at based on what he wrote in your moms chart. If mom needs Medicaid to pay, then find one that takes Medicaid & determine which dpoa will take the lead in the application & documentation gathering and let them do it.
If a change to skilled or specialty nursing facility provides the level of care she needs, then it's the route to go. Hopefully mom has the $$$ for private pay.
This is not proper procedure, under Any circumstances!
If she's in a NH, usually all care plan determinations to go through the medical director of the NH with staff (PA, nursing) carrying out plan with DON running herd. DON in my experience is goddess & ruler at NH & AL as DON there every day & with a direct underling RN for each wing or floor. DON power center.
For an outside MD to place orders for care poses problems for a facility. Like say there's edema & an outside MD writes orders for XY&Z to be done 3x a day and ABC every other day..... so who is going to do this? Resident has a care plan in place already..... medical director has their own orders in place... staffing schedules set.
Outside MD now making moms NH care a la carte. Now if you, mom, your family can pay $$$$ totally on your own to have outside nursing staff (with approval of facility) come in and do whatever, then fabulous. But that's not the situation now is it..... your expecting facility to do whatever this cardiologist orders. For facilities, it's not feasible to do unless this is a very high end private pay place. Be careful in wanting this, facility can determine that the level of care is beyond their capability and mom is issued a 30 day notice which means she now has to find a a la carte private pay facility. Very very expensive so I hope she has funds to afford 20k a mo.
For us, the yr before mom moved from IL into a NH she had out patient eye surgery - retinal specialist - 1 eye and with plan to evaluate other eye following year. Now post surgery care involved lots of monitoring so she stayed evenly elevated, special diet so no straining..... basically 24/7 continuous oversight for about 10 days done by me, a cousin & with Home Instead coming in 3 times a week for their minimum. Mom was a good Pt & still very competent at the time so all good. When I brought up doing other eye at moms initial care plan NH meeting, nursing was quite direct as to what would need to happen..... either she was hospitalized & stayed for post care then back to NH or moved to 1 of the isolette single bed rooms at NH & I hired private duty care from a list they provided & paid the up charge for single bed. Fortunately retinal guy gave mom the all ok so no surgery. But it did make me realize that NH have to have bright lines as to who is in charge of determination of care plan. If they are on Medicaid or LTC insurance, the medical director needs to be it. If their private pay then you have the $$$$ to do a la carte care.
I have decided to speak to the Director of Nursing with my concerns about this PA. I appreciate ALL the good counsel!
I still think that kind of comment by a PA is inappropriate and wonder if this person wasn't fired or encouraged to find employment elsewhere.
The PAs in our cardio's office could easily be mistaken for doctors; they're that knowledgeable. They've gathered information, asked insightful questions, then discussed with a cardiologist who then made recommendations.
Other doctors "keep having" people come back for similar reasons, especially pulmonary doctors. They monitor through tests and determine whether there have been changes, positive or negative, and act appropriately.
I still question a PA who feels this is inappropriate; there are some doctors who do abuse the "return in 3 months" approach, but cardiologists especially need to monitor on a regular basis.
What is the cardiologist's plan of action and is THAT what the PA is unhappy about?
When I moved my mom from her home to Ind Living, we ditched most of her doctors for a lovely Geriatrician. He took mom off all of her cardiac drugs. Nothing terrible happened. She had CHF and it progressed very slowly.
If a doc is going to prescribe meds, there needs to be followup.
It seems to me what wants examining here are the courses of treatment each of these medical professionals is recommending.
I absolutely agree with GA that if the PA told you the cardiologist is just looking for money, that should be reported to the DON and the director of the facility.
But....is there any possibility that what the PA said was interpreted by your sis, or embroidered a little? Just make sure before you go charging off.
I don't know of any legitimate, responsible, reliable and professional PA who would give the advice of which you wrote.
Adding, after thinking a few more minutes, that this PA is probably in violation of professional standards of the AMA.