Promoting Excellence : Rural Primary Care

Adjuvant Therapies, Inc.
Lake, Michigan

Kim Kuebler, MN, RN, ANP-CS

Kim Kuebler Kim Kuebler started Adjuvant Therapies, Inc., as a community-based primary care practice with an emphasis on palliative care. Her practice illustrates the potential role for the advanced practice nurse in providing continuity and coordination of care for patients living with and dying from advanced illness. Kuebler is an adult nurse practitioner and clinical specialist in oncology who serves as a primary care provider for her patients. She focuses on integrating palliative care into traditional health services for the underserved, sparsely populated, rural community of Lake in central Michigan (population: approximately 25,000). Kuebler patterned her practice model after Great Britain’s Macmillan nurses, who are trained to complement physicians and public health nurses in providing continuous, coordinated care for people with advanced, incurable illness and for their families.

Kuebler follows her patients throughout their illness, helping them and their families make the transition to palliative care as their disease progresses and the end of life nears. She provides case-managed care by accessing appropriate community and specialty physician referrals to meet individual patient and family needs. She also focuses on secondary prevention of problems to which patients with chronic illness are prone.

As a nurse practitioner, Kuebler performs comprehensive physical examinations, orders and interprets diagnostic tests and prescribes medications. Because APNs in Michigan cannot prescribe Class II medications, such as opioid analgesics, Kuebler has a collaborative practice arrangement with two internal medicine physicians who can prescribe appropriate pain medications based upon her assessment and recommendations.

Kuebler carries an average patient census of 350 active patients; approximately 45 to 50 are seen in their homes. Eighty-five percent of the care Kuebler provides is palliative in nature. “I follow patients back into their home setting,” she explains, “making sure they have the services that they need, including physical, occupational or respiratory therapy, skilled nursing care, senior services and/or hospice care.” Kuebler makes many weekend home visits to prevent crises and respond to exacerbations of pain and other symptoms.

In addition to her collaborative practice arrangement with the internal medicine physicians, Kuebler also works with a clinical psychologist and a massage therapist. When patients are referred to hospice, Kuebler directs their medical management and continues to see them until their death. She also attends hospice interdisciplinary team meetings. Kuebler bills under traditional codes and receives reimbursement from Medicare, Medicaid and third-party payers. She bills for her services as a nurse practitioner in private practice, independent from hospitals, clinics or long-term care facilities.

Getting Started
Kuebler says that starting her practice has not been without difficulties. “It’s been hard,” she reports. “At first, other providers resented a nurse practitioner working in the community. I struggled for hospital privileges and met constantly with the CEO and with local physicians.”

During her three years of service, Kuebler has seen more than 2,000 patients. Some of her original patients are still alive and continue to derive comfort from Kuebler’s services. Patients who have died under her care have commonly been served by hospice for six to eight months, far exceeding the national average for hospice length of stay. “My patients are not abandoned. They continue to see me until the end,” Kuebler explains.

“I started out as a hospice nurse,” she continues. “I understand case management and make sure that my patients are not falling through the cracks, that all of their needs are addressed and that services are based upon individual preferences. My patients and their families are very satisfied. By making routine phone calls to my patients, I ensure that any emerging problems are caught early and managed.”

Sharing the Knowledge and Experience
Kuebler opens her doors to undergraduate and graduate nursing students from all over the United States. To date, 10 graduate students have worked side by side with her for up to three days. She also takes two or three local associate degree nursing students on home visits during each semester.

Recently, Kuebler was funded by the Michigan Department of Community Health to work in partnership with the Michigan Nurses Association to produce palliative care self-training products and a clinical consultation Web site. These resources will be integrated into six graduate nursing curricula in Michigan and within the Veterans Administration nationally.

Kuebler and her colleagues also published End-of-Life Care Clinical Practice Guidelines (W.B. Saunders), the first textbook of its kind to address evidenced-based clinical aspects of palliative care for the advanced practice nurse.

Kuebler believes that anyone can emulate her model. “I’m not creating any new reimbursement structure,” she says. “I am using traditional reimbursement codes while demonstrating a specialty in palliative practice. I am able to provide continuity and coordinated care in a cost-effective fashion.”

Personal Reflection
“Persevere” is the single most important piece of advice Kuebler offers to nurses interested in pursuing a career similar to hers. “What you have to offer is unique. It does make a difference and improves patient outcomes,” she says.

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

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