INQRI Advisor to Lead Study on Nurses’ Impact

A new survey of more than 250,000 registered nurses (RNs) will help to generate evidence about how nurses impact the outcomes of their patients, according to a Nurse.com article. INQRI Research Manager and National Advisory Committee Member Linda Aiken will lead the survey of RNs and Nurse Practitioners holding active licenses in California, Florida, New Jersey, and Pennsylvania.
 
Aiken is the director of the University of Pennsylvania, School of Nursing’s Center for Health Outcomes and Policy Research (CHOPR). The National Institute of Nursing Research provided a $2.9 million grant to CHOPR for the survey, which is titled Panel Study of Effects of Changes in Nursing on Patient Outcomes. RWJF, the National Council of State Boards of Nursing, the Hillman Foundation, and the Boettner Center also provided funding.

“Our study will examine organizational-level changes over time in nurse inputs in education, staffing, skill mix, and work environment between 1999, 2006 and 2015,” Aiken said in a statement on CHOPR’s website. “The great strength of this project is that in creating a panel of organizational observations, we can see where change has occurred and why.”

States Benefit from Increased Autonomy for Nurses

States that allow Advanced Practice Registered Nurses (APRNs) to practice independently saw an improvement in health outcomes for patients and decreases in costs to Medicare and Medicaid, according to a study by researchers at the Missouri University Sinclair School of Nursing, Nurse.com reports.

The study, “Impact of Nurse Practitioners on Health Outcomes of Medicare and Medicaid Patients,” was published in the November-December issue of Nursing Outlook. Researchers analyzed previous studies with data on Medicare and Medicaid patients and found that states with full practice of nurse practitioners have lower hospitalization rates in all of the groups examined.

An INQRI-funded study, "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics,” found similar cost savings at retail clinics in states where nurses had more independence. The study, co-led by Joanne Spetz and Stephen Parente, found that visits to nurse-managed retail clinics were associated with lower costs, and the costs were even lower when Nurse Practitioners (NPs) practiced independently. The researchers concluded that eliminating restrictions on NPs’ scope of practice could have a large impact on the cost savings that can be achieved by retail clinics.

Government Report Shows Increase of Nurse Practitioners in Primary Care

After declining for two decades, the rate of recently licensed nurse practitioners (NPs) joining the primary care workforce is moving upward, according to a new report from the Health Resources and Services Administration (HRSA).

According to the National Sample Survey of Nurse Practitioners, in 1992, 59 percent of graduating NPs worked in primary care, but that decreased to 42 percent between 2003 and 2007. The new survey, based on 2012 data, shows that 47 percent NPs who graduated since 2008 have entered primary care, Nurse Zone reports. Survey results also showed:

• 94 percent of that total NP workforce held a graduate degree in some field, 86 percent had a master’s degree in nursing, and 5 percent held a doctoral degree in nursing;
• 76 percent of the NP workforce maintained certification in a primary care specialty (family, adult, pediatric, or gerontology); and
• More than half of the NP workforce worked in ambulatory care settings, with nearly a third practicing in hospitals.

Two recent studies funded by INQRI found significant benefits of NPs working in primary care. The first, led by Joanne Spetz at the University of California, San Francisco, found that increasing use of retail clinics in which nurse practitioners provide primary care and practice independently, can dramatically reduce health care costs, as much as $810 million in 2015, if those clinics account for 10 percent of outpatient primary care visits.

The other, led by David Auerbach of RAND and funded in part by the Donaghue Foundation, found that increasing the number of and the use of models of health care delivery that rely on nurse practitioners or physician assistants as primary care providers could offset the expected primary care physician shortage in 2025.

Expanding Scope of Practice for NPs could save California nearly $2 Billion

Over the next 10 years, California could improve patients access to health care and save $1.8 billion in medical costs if nurse practitioners (NPs) were allowed to practice to the full extent of their education and training, according to a new report from the Bay Area Council Economic Institute funded by the Robert Wood Johnson Foundation and AARP. INQRI grantee Joanne Spetz contributed to the report.

According to the Council, with 3.3 million more Californians having access to health insurance under the Affordable Care Act, allowing NPs to practice independently from doctors is "one of the most effective steps" the state could take to meet the expected increase in demand for primary care providers, FierceHealthcare reports. Expanding scope of practice would increase the number of NPs practicing by 24 percent and would also allow more currently medically underserved communities to gain access to care.

The report reveals that full practice authority for NPs is associated with lower costs for common procedures and does not decrease quality of care: "In states with limited NP practice authority, the average cost for a preventative care visit can be as much as $16 higher than in states with full practice authority. We estimate scope of practice reform in California would save $1.8 billion in the cost of preventative care visits alone over the first ten years."

• The Council's report is available here.
• A statement on the report from the California Association for Nurse Practitioners is available here.

The INQRI-funded study "Scope-Of-Practice Laws For Nurse Practitioners Limit Cost Savings That Can Be Achieved In Retail Clinics” was co-led by Spetz and Stephen Parente.

The Nursing Profession in 2014

Top nursing leaders make predictions of nursing trends to watch for in 2014, based on what has been happening in the field over the past year, in a recent NurseZone.com article.

Leaders agree that the profession will continue implementation of the Institute of Medicine’s (IOM’s) 2010 landmark report The Future of Nursing: Leading Change, Advancing Health recommendations, which include increasing the presence of nurses on hospital, state, and federal boards.

Without nurse leadership on boards “… our perspective is missing, and it’s an important perspective,” said Karen Daley, PhD, RN, FAAN, president of the American Nurses Association. “We speak for the patients. There’s no one closer to the everyday needs and care that we provide.”

Focus on patient safety, particularly in the areas of alarm management and the prevention of healthcare-acquired infections will also continue to be priorities for the industry, according to Vicki Good, RN, MSN, CENP, president of the American Association of Critical-Care Nurses.

Rollout of the Affordable Care Act (ACA) will continue to have an impact on nurses, including increased use of community-based settings for health care delivery, Daley said. New nurses may begin their careers in such settings, rather than at hospitals. As a result, the educational system may need to recognize and accommodate this trend, Daley said.

The Future for Nurse Practitioners 

The momentum to expand scope of practice for nurse practitioners could continue to build in 2014. In 2013, Nevada became the most recent state to pass a law granting nurse practitioners the freedom to practice independently, bringing the total to 17 states.

“I believe that other states will move slowly but will eventually see the resource that they have in nurse practitioners and be more willing to grant them the ability to practice in accordance with their education,” said Kenneth P. Miller, PhD, RN, CFNP, co-president of the American Association of Nurse Practitioners.

As the ACA seeks to increase medical services for the previously uninsured and underinsured, nurse practitioners must be included. “It is going to take all health care providers working together to achieve that goal,” Miller said.

Opportunities and Challenges Ahead

As the economy improves, many nurses may finally retire, leaving job openings for newer nurses in clinical settings. However, this trend could be a challenge for the academic world as nursing educators and nursing school deans retire and leave gaps that may be difficult to fill, experts said.

The nursing leaders told NurseZone that individuals must remember why they went into nursing and keep their focus, no matter what the future holds.

Could Alternate Primary Health Care Centers Mitigate the Anticipated Physician Shortage?

A new study from the INQRI-coordinated Future of Nursing National Research Agenda, featured in the November issue of Health Affairs, finds that increasing the number of nurse-managed health centers and patient-centered medical homes could mitigate the projected physician shortage. These institutions rely less on physicians as primary care providers, and more on nurse practitioners (NPs) and physician assistants (PAs).

The research team, led by David Auerbach, MS, PhD, a policy researcher at the RAND Corporation, calculated how many physicians would be required to provide primary care in 2025 under various scenarios involving increased demand for those services, and that included expanding the number of patient-centered medical homes and nurse-managed health centers. The was co-funded by the Donaghue Foundation.

The researchers noted that while studies project an increase in the numbers of clinically active full-time-equivalent primary care physicians, NPs, and PAs, stronger growth is expected for the latter two providers. For instance, while there were four primary care physicians for every primary care NP in 2010, projections suggest that there will be just over two physicians per primary care NP in 2025. Assuming no growth in medical homes or health centers, the research team projected a shortage of 45,000 primary care physicians in 2025 (putting supply 20 percent below demand), a surplus of 34,000 NPs (48 percent higher than demand), and a surplus of 4,000 PAs (10 percent higher than demand).

They found that medical homes and health centers tend to provide primary care services to the same population as traditional models, but with fewer physicians. Therefore, increasing the prevalence of medical homes from providing 15 percent of the nation’s primary care in 2010 to providing 45 percent in 2025 would reduce the primary care physician shortage by a quarter to 35,000. Increasing the prevalence of nurse-managed health centers from providing .5 percent of the nation’s primary care in 2010 to 5 percent in 2025 had roughly the same effect. Greater prevalence of both health care delivery models (about half of all primary care delivered in health centers and medical homes), would cut the physician shortage nearly in half. If medical homes are able to leverage their comprehensive approach to treat more patients, the shortage could be eliminated.

The authors also note that increasing the number of nurse-managed health centers and patient-centered medical homes may require changing some state laws to allow NPs and PAs to play expanded roles in primary care. They point out that this will increase the need for medical assistants, licensed practical nurses and other providers who perform key functions in integrated care models. It may also require changing payment structures to reward providers for managing population health rather than a fee-for-service model. More information about the study is available here and an abstract of the study is available here.

INQRI Study Shows Retail Clinics are Convenient, Cost-Effective, Provide Quality Care

A new INQRI-funded study shows that retail clinics can reduce costs when Nurse Practioners (NPs) are allowed to practice independently, potentially by nearly $472 million or more in 2015.

Retail clinics are an increasingly popular option for people who need diagnosis and treatment for common, non-life-threatening conditions. NPs are the primary care providers in these clinics, which are located in a range of settings, including pharmacies, grocery stores and “big box” stores. First established in 2000, there are now more than 1,200 retail clinics nationwide.

The research team for the study was led by Joanne Spetz, professor at the Institute for Health Policy Studies and associate director for Research Strategy at the Center for the Health Professions at the University of California, San Francisco, and Stephen Parente, director of the Medical Industry Leadership Institute at the Carlson School of Business, University of Minnesota. The team compared claims data over a two-week period for 9,503 patients who visited retail and non-retail clinics from 2004 to 2007. Researchers compared costs in states that require NPs to be supervised by or collaborate with physicians, states that allow NPs to practice independently but not prescribe, and states in which NPs are allowed to practice and prescribe independently. The study is in the November issue of Health Affairs.

The researchers found that insurance claims over a two-week period were lower following retail clinic patient visits than after visits to other settings, such as doctor’s offices and emergency departments, for the same conditions. Insurance expenditures for retail patient visits were even lower in states that allow NPs to practice independently. Payments for prescriptions were slightly higher in states where NPs are allowed to prescribe, but that increase in cost was mitigated by the lower cost of an NP practicing independently.

Adjusted to 2013 dollars, the average two-week cost for non-retail clinic visits was $704, for retail clinic visits in states with no NP independence it was $543, and for retail clinic visits in states where NPs have independence in practice, it was $484. The average cost for retail clinic visits in states where NPs had independence in practice and prescribing was $509.

Retail clinics are projected to account for about 10 percent of outpatient primary care visits by 2015. The study’s authors projected that the cost savings realized from using retail clinics at that level would be $2.2 million. The savings would be increased by $810 million if all states allowed NPs to practice independently and by $472 million if NPs were allowed to practice and prescribe independently.

Read the study.

Article: States with Least Restrictive Regs on NP Practice Have Largest Increase in Primary Care Delivered by NPs

In a new Health Affairs article, Yong-Fang Kuo and colleagues present recent findings which demonstrate that states with the least restrictive regulations on nurse practitioner (NP) practice experienced the largest increase in the number of patients seen by NPs.  Further, the team found that between 1998 and 2010, the number of Medicare patients receiving NP-delivered care increased fifteenfold.  The authors suggest that relaxing restrictions on NP practice could increase the use of NPs as primary care providers, which could then reduce the shortage of primary care providers we are currently seeing across the country.

For more information, please read the article on the Health Affairs website.

NP/Physician Teams Improve Outcomes

A recent study at two primary care facilities in California focused on 1,084 patients who were screened for four chronic geriatric conditions: falls, urinary incontinence, dementia/Alzheimer's disease and depression. Six hundred and fifty eight of these patients had at least one condition; 485 of those were then randomly selected for medical review. Researchers found the percentage of quality indicators that were satisfied for patients whose cases were co-managed by a nurse practitioner and a physician was higher than for those seen only by a physician.

To learn more, check out this news story on UPI.com.

Marketplace Health Care: The Nurse Practitioner Will See You Now

 

This Marketplace podcast by Dan Gorenstein looks at the role of nurse practitioners as approximately 30 million Americans gain health insurance under the Affordable Care Act.

Listen to/read the podcast here.

Removing Barriers to Practice & Care

The Diane Rehm Show Discusses the Role of Nurse Practitioners

In 18 states and the District of Columbia, nurse practitioners (NPs) are allowed to treat patients and prescribe medications without a doctor's involvement. Lawmakers in a number of other states are pushing for similar changes to existing laws that place unnecessary barriers in between nurse practitioners and patients.

Last week, Diane Rehm hosted a discussion on the role of nurse practitioners on her nationally-syndicated radio show. Can removing these barriers help NPs address the shortage of primary care physicians? Does a team-based approach including a medical doctor result in better care for patients?

Listen to the show here.

Diane's guests included:

• Dr. Reid Blackwelder: family physician and president-elect of the American Academy of Family Physicians. 
• Mary Agnes Carey: senior correspondent for Kaiser Health News. 
• Ken Miller: nurse practitioner, associate dean at The Catholic University of America School of Nursing, and president-elect of the American Association of Nurse Practitioners. 
• Sandra Nattina: nurse practitioner at Columbia Medical Practice in Columbia, Md., and past president of Nurse Practitioner Association of Maryland. 

New Report on Health Reform Highlights Role of Nurse Practitioners

A new report by the National Institute for Health Care Reform digs into a topic of increasingly heated debate in health care — the role of nurse practitioners in addressing an anticipated shortage of primary care physicians.

From a recent article in the Baltimore Business Journal: the institute’s report said that state laws themselves do not restrict what services nurse practitioners can provide but the laws can indirectly affect nurse practitioners’ ability to practice. Considering the big demand for primary care services analysts are predicting, states might want to adjust their regulations to more explicitly define nurse practitioners as primary care providers, the report concluded.

View the entire article.

Next WIHI on Jan. 10: Navigating New Care Teams with Nurse Practitioners

WIHI is kicking off the new year, on January 10 (2p-3pET), with a show on Navigating New Care Teams with Nurse Practitioners. Discussion will explore how nurse practitioners or advanced practice nurses are being deployed and woven into new, interdisciplinary, team-based delivery designs. The participating guides are four individuals who are engaged in both pioneering and common-sense solutions to patient needs in ways that match the right caregivers with the right patients and the right needs.

At the Robert Wood Johnson Foundation, Susan Hassmiller has a bird’s eye view of where and how nurses across the US are contributing at the top of their education and training; Cathy Rick, at the VA, is overseeing the implementation of a new national strategic plan to better align nursing services with new systems of care for some six million veterans who use the VHA; Patricia Gerrity directs a nurse-managed community health center in North Philadelphia; and, in addressing the health needs of teenagers, physician Daryl Lynch has created deep and effective collaborations with nurse practitioners.

There are challenges to getting the care team right, and disagreements over roles and functions. But as you’ll learn from the guests on the January 10 WIHI, there’s also a new spirit of forging ahead given the growing emphasis on primary care in a rapidly reforming health care system.

Please click here to enroll.

Unique Collaboration to Reduce ED Visits

Midland Fire Department and Midland Memorial Hospital in West Texas are partnering in a unique way to try to reduce emergency department (ED) visits.  In a new plan, a nurse practitioner or physician's assistant will be added as part of the emergency medical services.  The goal is to have the additional medical professionals available to provide mid-level care when an ambulance is dispatched in non-emergency situations.

Cutting down on overuse of the ED will not only impact the doctors and nurses in that department, but will also have positive effects on other hospital departments, including radiology and labs.

For more details, check out the story on MyWestTexas.com.

Solving Many of the United States' Primary Care Challenges

With the Affordable Care Act being upheld earlier this summer, there will a large flux on individuals with insurance coverage that require primary care. As many of our previous blog posts have already discussed, there is already a primary care provider shortage and this shortage is expected to grow even further after 2014.

The most recent Charting Nursing's Future, published by the Robert Wood Johnson Foundation, highlighted how nurses can help solve many of primary care’s most pressing challenges, including access and cost.

Gene Steuerle, writing for his own blog, The Government We Deserve, also focused on the role of nurses in reducing costs while providing the same level, or even better care than physicians for many basic services. Mr. Steuerle, who is a renowned economic and tax expert, argued that the current primary care provider shortage is a result of an uncompetitive industry unwilling to relinquish control over services that many non-physicians have the training and education to provide.

Finally, a collaborative group of scholars published a thorough article in the New England Journal of Medicine, highlighting how our health system can reduce costs while improving care. The utilization of nurses and other allied health professionals was highlighted by the authors as an integral piece of reforming our broken health system.