The Leaf system is a wearable sensor that electronically monitors a patient's position and movements and then wirelessly communicates the data collected to central monitoring stations or mobile devices so that nurses and other caregivers can check on patient position and movement. The Leaf sensor also will sound alerts when necessary to ensure that all patients are repositioned according to established turning schedules, to reduce the incidence of pressure ulcers.
Results of the clinical trial were presented this month at the American Nurses Credential Center National Magnet Conference in Dallas. The trial found that use of the monitoring device increased compliance with hospital turn protocols from a baseline of 64 percent at the start of the trial, to 98 percent after the system was implemented.
The INQRI funded project “Interdisciplinary Mobility Team Approach to Reduction of Facility-Acquired Pressure Ulcers” developed a sustainable, system-wide program for pressure ulcer prevention that enhances mobility of long-term care (LTC) residents. The primary goal, under nursing's leadership, was to reduce LTC facility-acquired pressure ulcer incidence by 50 percent using a cost-effective innovative program to increase resident active or passive movement. The team, which developed and implemented a program that involved using musical cues to remind residents to move or staff to help residents move, was led by Tracey Yap, a nurse researcher, and Jay Kim, an engineer.
Last week, the U.S. Supreme Court heard arguments in North Carolina State Board of Dental
Examiners v. Federal Trade Commission (FTC), a case that will have
significant implications for scope of practice regulations across the
country.At the center of this case is
the “state-action doctrine,” which provides immunity from federal antitrust
liability for certain state-mandated activities. In this case, the FTC had
filed a complaint regarding the Board’s efforts to stop non-dentists from
offering teeth whitening services. The North Carolina Dental Board asserted
state-action as a defense. The case centers on how the Board operates and whether
its operations fall under the state-action doctrine. The FTC believes that the
board, which is comprised mainly of practicing dentists, exceeded its authority
and its actions were a private effort to eliminate competition from
non-dentists – a violation of anti-trust law. The Board believes it is acting
as a regulatory body to ensure consumer safety.
Last spring, the 4th Circuit Court of Appeals
agreed with the FTC; the Board appealed to the Supreme Court. This case gives
the Supreme Court an opportunity to decide whether health professions boards in
general, which are usually established by state legislatures but whose members
are private actors, fall under the state-action doctrine. If the Supreme Court
sides with the FTC, it could have a significant impact on the capacity of
dental, medical, nursing, and other boards to regulate health care services,
especially when a compelling public safety argument cannot be made.The Supreme Court’s decision also could provide
clear guidance to states in how their boards can be appointed and function in
order to adhere to anti-trust law. To follow the case’s history, look here.
This same issue was addressed last June at an FTC public
workshop in Washington, DC, titled, “Examining
Health Care Competition.” The workshop topics included professional
regulation of health care providers, health care delivery innovations such as
retail clinics, health information technology, health care quality, and price
transparency. The meeting room was full for most of the two-day event, but
attendance appeared greatest for the first session, “Professional Regulation of
Health Care Providers,” for which I was one of the presenters.
The session did not address any specific legal action
related to health professions regulation, focusing instead on providing an
overview of several important aspects of health professions regulation.Barbara J. Safriet, JD, LLM, a Visiting
Professor of Health Law and Lewis and Clark Law School, discussed the history
of health professions regulation and the potential for legal collusion and
hindrance of competition. Morris Kleiner, PhD, from the University of
Minnesota, discussed health professions regulation in the context of
professional regulation in general. He noted that health professions boards are
often based at the same agencies as many other professions’ boards, so a single
organization is charged with overseeing physicians, nurses, cosmetologists, pet
groomers, and myriad other professions. Gail Finley of the Colorado Hospital
Association discussed particular challenges that state faced regulating nurse anesthetists,
and the battle between physicians and nurses regarding safe anesthesia care in
rural communities. I discussed the impact of scope of practice regulations for
licensed practical/vocational nurses on the demand by hospitals and nursing
homes – we found that in states with stricter regulations, there is lower
The FTC published a Policy
Perspective paper in March 2014 on “Competition and the Regulation of
Advanced Practice Nurses.” The paper’s
authors reviewed the rationale for establishing scope of practice regulations,
noting that there are valid reasons to control scope of practice, even if it
might reduce competition. However, they wrote: “…the FTC staff has consistently
urged state legislators to avoid imposing restrictions on APRN scope of
practice unless those restrictions are necessary to address well-founded
patient safety concerns. Based on substantial evidence and experience, expert
bodies have concluded that ARPNs are safe and effective as independent
providers of many health care services within the scope of their training,
licensure, certification, and current practice. Therefore, new or extended
layers of mandatory physician supervision may not be justified.”
Unsurprisingly, there is great interest in the Supreme Court
case throughout the health care industry. Among the entities that have filed
amici briefs, are the American Dental Association, Federation of State Boards
of Physical Therapy, American Association of Nurse Anesthetists, Association of
Dental Support Organizations, Cato Institute, Pacific Legal Foundation,
National Governors Association, California Optometric Association, and Public
Citizen, and 23 states.A decision is
expected next year.
Joanne Spetz is a professor at the Philip R. Lee
Institute for Health Policy Studies and associate director of research strategy for the Center for the Health Professions at the University of California, San
Olga Jarrín, PhD, RN @OJ_RN National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing
The Affordable Care Act has generated carrots and sticks for hospitals to reduce readmissions. With the goal of achieving the Triple Aim (improving quality of patient care, improving population health, and reducing overall cost of care), innovative care delivery models are being tested locally and nationally, including the roll-out of Accountable Care Organizations and bundled payment programs. These programs create incentives in terms of shared savings for health care systems that provide high quality, coordinated care.
Olga Jarrín is a National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow at the Center for Health Outcomes and Policy Research.
Meanwhile, a readmission penalty has taken effect, and hit safety net and teaching hospitals hard. While increased referrals to home health care from hospitals might lower readmission, there is wide variation in home health agencies’ ability to keep patients safely in their homes, and out of the hospital.
Institute of Medicine Workshop on the Future of Home Health Care
Health services researchers, home health agency executives, other industry representatives, and stakeholders including patients and patient advocates met at the Institute of Medicine for a 2 day workshop on the Future of Home Health Care#FutureofHH September 30-October 1, 2014. Major challenges for home health include reduced/insufficient payment for home health care, misaligned regulatory requirements and statutes, and the image of the home health care industry, that has been tainted with fraud, abuse, and sub-optimal patient care. Core issues discussed at the meeting included the use of technology to enhance care, the need for interoperable health records, the need for statutory changes at the federal level to allow advanced practice nurses to sign orders for home health care, and new models of care.
In contrast, the existing way that home health care is provided to Medicare beneficiaries was criticized as fragmented, uncoordinated, siloed, slow, and unable to meet the functional or clinical needs of today’s population. The desire to scrap the entire system and start over was balanced by a call for action “Let's work to improve, not diminish our existing home health care system” from keynote Steve Landers, MD, President and CEO of VNA Health Group. Reminding the audience of the Jimmo v. Sebelius Settlement Agreement, Judith Stein, JD, founder and Executive Director of the Center for Medicare Advocacy, pointed out the discrepancy between how home health care has been provided to Medicare beneficiaries, and how it should be provided.
Home Health Agency Work Environment Study
Using publicly reported CMS Home Health Compare data linked with nurse-reported ratings of the home health agency work environment, researchers from the Center for Health Outcomes and Policy Research have established a mechanism for why some home health agencies have better outcomes. Hospitalizations, including both acute and long-term stays, were lowest for patients receiving services from home health agencies where nurses reported excellent working conditions. Nurses working in home health agencies with poor working conditions were much more likely to report being unable to complete necessary care coordination and patient teaching due to time constraints. These findings are published open access in the October issue of the journal Medical Care.
These findings have implications for hospital and home health administrators, as well as policymakers. Hospitals should consider partnering with home health agencies that have better nurse work environments as a strategy to improve their patient outcomes, and bottom line. Home health agencies should work towards creating optimal conditions for nurses to care for patients. Policymakers should remove barriers to full scope of practice for Advanced Practice Nurses (APNs) and Registered Nurses (RNs) working in home health care, especially the requirement for physician co-signatures of APN orders for changes to the home health plan of care, including medication changes. The federal statute restricting APN authority supersedes state laws, and provides a disincentive for home health agencies to hire and collaborate with expert nurse clinicians.
Some of the “new” care models highlighted at the IOM Workshop: The Future of Home Health Care were strikingly similar to old models of home health care provided by public health district nurses and community-based family practice doctors who made both house-calls and hospital-rounds. Removing barriers to practice in home health care for APNs to direct care and directly order services is a small but important step towards raising the quality, responsiveness, and cost-effectiveness of home health care.
This post first appeared on the Leonard Davis Institute of Health Economics Blog (LDI Blog) of the University of Pennsylvania.
Identifying the reasons for racial health
disparities and ways to address them is a significant, complex challenge in
health care. A new INQRI-funded study led by Eileen T. Lake, PhD, RN, FAAN and Jeannette A.
Rogowski, PhD, provides insight into the issue of very
low birth weight (VLBW) infants, who are disproportionately black, and finds
that it’s not just their race that’s a factor in their health outcomes, it’s
the quality of care at the hospitals where they’re born. The study was
published in the journal Health Services Research.
The research team examined data on 8,252 VLBW
infants in 98 Vermont Oxford Network member neonatal intensive care units
(NICUs) throughout the country and the results of a survey of 5,773 NICU
nurses. They found that nurse understaffing and practice environments were
worse at hospitals with higher concentrations of black patients, contributing
to adverse outcomes for VLBW infants born in those facilities.
Since 7 out of 10 black VLBW infants are born in
hospitals with a high concentration of black patients, researchers concluded
that improvements in nursing at such hospitals have the potential to boost the
quality of care for many black VLBW infants. The study looked at two
nurse-sensitive perinatal quality standards—hospital-acquired infection and
discharge without having started breast milk, which have long-term health
implications for VLBW infants—and found higher rates of both in
high-black-concentration hospitals. NICU nursing features ultimately accounted
for one-third to one-half of hospital-level health disparities.
“Very low birth weight infants are at a high risk
for a lifetime of health challenges,” said Lake. “The birth hospitalization is
the starting point.With a high number
of black infants born in relatively few hospitals, tackling a previously
unaddressed question—do infants cared for in hospitals with a high
concentration of black infants have poorer perinatal quality outcomes?—gives us
an opportunity to make a positive impact on population-level health
The study highlights dramatic differences in the
distribution of care for black infants, with nearly three-fourths of black VLBW
infants born in a third of hospitals that care for critically ill newborns.
Only 1 in 20 black infants are born in hospitals with better nursing
characteristics, and odds of adverse outcomes related to nurse-sensitive
perinatal quality standards are at least 60 percent higher for infants born in
disproportionately black hospitals.
The team also included Jeffrey Horbar, MD, chief
executive and scientific officer, Vermont Oxford Network and professor of pediatrics, University of
Vermont; Michael Kenny, MS, research biostatistician, University of Vermont;
Thelma Patrick, PhD, RN, associate professor, the Ohio State University College
of Nursing; and Douglas Staiger, PhD, professor of economics, Dartmouth
Alyce Ashcraft, associate dean for research at the Texas Tech University School of Nursing, is conducting a study with a customized Situation, Background, Assessment and Recommendation (SBAR) tool that gathers additional patient information and forces more transparency in nurse-provider communication.
Over a 16 week-period, Ashcraft instructed nurses at a retirement community in Lubbock, Texas, to document all of their consultations with health care providers, including phone and fax communications, on SBAR forms. The intent is to eliminate repeats tests and create more efficient care by recording when nurses contact other providers about a patient’s condition, and the actions taken. The data is still be collected and analyzed.
“I don’t care if you’re here in long-term care, or the hospital or home health, it doesn’t matter,” Ashcraft, told the Journal. “Communicating the right information and getting the residents’, the patients’, the clients’ story right so that decisions can be made that are good for them; [t]hat’s what we hope to do.”
Advance Healthcare Network for Nurses is hosting a webinar on the issue of nurses facing alarm fatigue. The webinar is scheduled for Thursday, October 16, 2014 from 3:00pm-4:00pm ET. The webinar will provide information about:
Current literature on alarm fatigue.
Systems and human issues that contribute to alarm fatigue.
A system wide approach that can be developed to address alarm fatigue.
The webinar will also feature a question and answer session. Registration is available here. The webinar is sponsored by Covidien.
An INQRI-funded study found a unique way to use different sounds to reduce alarm fatigue and help keep patients safe. Led by Tracey Yap and Jay Kim the team used music to reduce the incidence of pressure ulcers. The study used music to cue patients in long-term care facilities to move in order to avoid getting pressure ulcers. The music also cued staff to help to move those patients who could not move on their own.
The Robert Wood Johnson Foundation’s (RWJF) LEAP NationalProgramis
working to create a culture of health by discovering, documenting and
sharing innovations in the primary care workforce. To advance this goal,
the program is holding a series of six webinars that highlight best practices. (Read a post summarizing the first of the six webinars.)
The second of the webinars in the series focused on team-based care for
complex cases. Presenters included leaders from four primary care sites
around the country that the LEAP program has deemed exemplars.
Managing Care for the Most Complex Patients
Kathy Bragdon, RN, director of care management at Penobscot Community
Health Center in Bangor, Maine, discussed the rapid growth of the
health center, and went on to describe its system of care management for
the most complex patients.
The center relies on a transitions care manager, who shares
information back and forth with the hospital and with patients’ medical
homes. In addition, the manager meets with patients when they are in the
hospital, looking to identify potential barriers to recovery and to
provide any needed referrals.
“One of the big roles—we didn’t realize how big—was that a tremendous
number of patients had no primary care at the time of admission,” she
said. “We worked really closely with the hospitals trying to provide
those services and make that linkage to those patients who needed
primary care providers.”
Bragdon explained that the center’s biggest initiative was to embed
care management at its larger facilities, using nurses, medical
assistants, health coaches and social workers focused on improving
patients’ self-management skills, thus reducing the number of
hospitalizations and readmissions, and improving the overall quality of
care. The initiative is built around face-to-face visits, as well as
phone calls with a focus on hospital follow-up. They try to reach every
patient within 72 hours after they’ve been discharged from acute care.
Finally, the center uses a community care team (CCT) to work on its
most complex cases. In addition to the supports provided via embedded
care management, the CCT conducts a team visit that includes both a
social worker and a nurse, meeting the patient where it is convenient
for them—at a doughnut shop, a homeless shelter, or wherever else makes
sense. “We do this because the RN and the social worker look at the
situation through very different eyes in trying to see what is driving
that person to the emergency room,” she explained, adding that the
effort is “focused on the highest utilizers of health care dollars.”
The cost savings generated by the CCT program are significant, she said, cutting costs to the state in half.
The Integrated Care Team
From Daughters of Charity Health Centers in New Orleans, Roslyn
Arnaud, RN, chief nursing officer, and Grace Mena, RN Care Manager,
discussed the center’s Integrated Care Team. Arnaud began by sketching
out the members of the team. They include:
An RN Care Manager, who identifies patients who are not being
treated appropriately by a primary care provider, generally at-risk
patients with comorbidities. The nurses respond to patients from local
safety net hospitals and provide intense follow-up support for them
after discharge. They help patients understand what took place and make
sure they have medications, have a follow up appointment with their
primary care provider and reconcile medications. The RN Care Manager is
also responsible for monitoring and tracking patients on anticoagulation
therapy. Additionally, they are responsible for overseeing the
tracking of abnormal cancer screens.
A Patient Care Coordinator, who provides administrative
support, including making appointments for patients for services the
Health Center does not have provide onsite. Coordinators also make sure
patients know about their appointments and work to ensure that they go.
They also ensure that preventive care is completed, including
mammograms, colonoscopies, pap smears, and other cancer-tracking.
A Behavior Health Social Worker, who serves as a consultant
to the patient, helping them identify the need for change, and
establishing goals that are appropriate for that patient.
The team members also collaborate with a local university to arrange
for the services of a clinical pharmacist and a certified asthma
Mena explained that the center is now testing a team model with a
different composition, bringing together a physician, nurse
practitioner, medical assistant and care coordinator, with social
workers also available to patients. She noted that the nurse
practitioner provides patient education and patient engagement. “The
key part of this work is communication between the nurse practitioner
and RN care manager,” she said.
Continuity and Coordination of Care for Complex Patients
Larry Holly, MD, CEO of Southeast Texas Medical Associates, then
discussed his six-site clinic’s efforts to care for complex patients as
they transition from one setting to another.
He said that the care transition process begins at hospital
admission, when the patient receives a care plan to transition from the
ambulatory to in-patient setting. Then, at the end of their hospital
care, the patient receives materials that detail necessary follow-up
appointments and include a medication reconciliation plan. Associates
follows that up with a “care coaching call,” and then the patient
completes the process with a follow-up appointment at the clinic.
Associates also uses a Hospital Consumer Assessment Health Care
Provider and Systems audit that assesses whether the care provided has
been patient-centered and of sufficient quality. It asks whether the
physician explained the care plan, answered all of patient’s questions
without interrupting, inquired about whether care at home was adequate,
and wrote down what potential symptoms would necessitate a return to the
hospital. The clinic reviews results of the assessment with the
Associates also features a Care Coordination Department that
identifies and tries to overcome barriers to care, Holly explained. So
if patients lack transportation to appointments, can’t afford their
medication, or are in need of dental care, the patient is referred to
Said Holly: “This system has integrated a number of complex problems
that have befuddled physicians for years. Now we can easily provide
those in the context of continuity of care and transitions of care for
complex patients. These are critical parts of a medical home.”
Expanding the Team for Complex Cases
Craig Robinson, MPH, executive director of Cabin Creek Health Systems
(CCHS), and Amber Crist, MS, CCHS director of education and program
development described their efforts to treat patients with chronic pain
using interdisciplinary teams.
CCHS has four sites in rural southern West Virginia, Robinson and
Crist explained. The program began with an effort to identify older,
frail patients in the area in need of care focused on reducing pain from
“We quickly realized [such patients] increase the complexity of our
system,” Crist said, going on to explain that the system needed to
adapt. “We needed to expand our clinical team. It couldn’t just be the
medical provider. Accordingly, the team grew to include the MD, a nurse
practitioner, a physician assistant, a medical assistant, a behavioral
health coach, a pharmacist, a health coach, and administrators.”
“If we can keep these patients out of the hospital, we save the
system money. That’s where the suffering, is and that’s also what’s
sometimes burning our staff out,” she said. “Our providers feel alone in
the room. [Otherwise,] they feel they don’t have anyone else to turn to
and are alone dealing with these complex patients.”
The primary goal of the Interdisciplinary Nursing Quality Research Initiative (INQRI) is to generate, disseminate and translate research to understand how nurses contribute to and can improve the quality of patient care.
The program supports interdisciplinary teams of nurse scholars and scholars from other disciplines to address the gaps in knowledge about the relationship between nursing and health care quality.
For more information on the INQRI program, see our website at www.inqri.org.