Expanded role of nursing in ambulatory managed care. Part I: Literature, role development, and justification

New expanded roles in nursing are developing in response to the health system switch from private, episodic care of individuals to health maintenance organizations (HMO's) focusing on disease prevention and promotion of health for populations of persons with chronic illness. This evaluation project explored the role of the nurse clinician in population and case management at a large HMO in the Northwest United States. In Part I of this two-part series, a literature review, is presented on chronic illness, ambulatory nursing, expanded role nursing, and nursing in HMOs. The development of the expanded role nurse clinician at the managed care organization is also described. Results could be used by HMOs to attract and retain nurses, improve care processes, and decrease costs in ambulatory care.     

Ambulatory care registered nurse performance measurement

On March 1-2, 2010, a state-of-the-science invitational conference titled "Ambulatory Care Registered Nurse Performance Measurement" was held to focus on measuring quality at the RN provider level in ambulatory care. The conference was devoted to ambulatory care RN performance measurement and quality of health care. The specific emphasis was on formulating a research agenda and developing a strategy to study the testable components of the RN role related to care coordination and care transitions, improving patient outcomes, decreasing health care costs, and promoting sustainable system change. The objectives were achieved through presentations and discussion among expert inter-professional participants from nursing, public health, managed care, research, practice, and policy. Conference speakers identified priority areas for a unified practice, policy, and research agenda. Crucial elements of the strategic dialogue focused on issues and implications for nursing and inter-professional practice, quality, and pay-for-performance.     

A model for testing the relationship of nursing care and patient outcomes

Studying patient outcomes alone may not provide enough information to determine the associated factors that must be improved when the desired patient outcomes are not achieved. The purpose of this correlational study was to investigate the effects of perceived quality of nursing care and coordination of care on patients' comfort, satisfaction, and length of hospital stay. The overall model-data fit was good according to four indices: the chi-square value, goodness of fit index, adjusted goodness of fit index, and the Steigers root square error of approximation. The proposed model, effects of care quality on patient outcomes, was tested. The relationship between quality of nursing care and the proposed outcomes was tested. The results provide important information to the nursing profession and policymakers in meeting patient care needs.     

Capacity planning in hospital nursing: a model for minimum staff calculation

An aging population, emerging technology, heightening patient expectations, rising health care costs, shorter patient stays, and growing pressure to improve quality have made the management of nursing resources even more critical today. While approaching a model for staffing levels, the authors considered factors such as patient acuity, work redesign, and minimum quality standards. The methodology for analysis included estimating the time needed to complete nursing tasks and calculating the average number of tasks per patient. With respect to nursing quality measures, the study examined the adequacy of nursing documentation including admission history, assessments, nursing procedures, and discharge report as well as nursing-driven outcomes such as fall and phlebitis rates. Lastly, the authors determined the theoretical number of staff needed to provide nursing care according to quality standards.     

The impact of nurse staffing on hospital costs and patient length of stay: a systematic review

Research examining the relationships between nurse staffing, hospital costs, and length of stay is varied using a range of methods and definitions. This lack of coherence in definitions and measurement tools for cost and length of stay makes it difficult to conclude with certainty the results of nurse staffing on hospital cost and length of stay. However, the evidence reflected that significant reductions in cost and length of stay may be possible with higher ratios of nursing personnel in hospital settings. Sufficient numbers of RNs may prevent patient adverse events that cause patients to stay longer than necessary. Patient costs were also reduced with greater RN staffing as RNs have higher knowledge and skill levels to provide more effective nursing care as well as reduce patient resource consumption. Hospital administrators are encouraged to use higher ratios of RNs to non-licensed personnel to achieve their objectives of quality patient outcomes and cost containment.     

Managed care, quality of care, and patient rights

The growth of managed care has been accompanied by calls for increased government regulation because HMOs and other forms of managed care are seen by the public as more concerned about controlling costs than with protecting the rights of patients to quality care. This paper applies a theory of health care rights and clinical evidence of managed care quality in an analysis of public opinion about managed care. The paper concludes that there is no persuasive evidence that managed care has resulted in a general deterioration in the quality of care and that, with one exception, restrictions imposed by managed care plans are consistent with a theory of health care rights. The paper concludes with the recommendation that public policy should dispense with attempts to fine tune managed care and address an unquestionable violation of health care rights, the failure to guarantee a minimum standard of care to some 43 million Americans.     

The searchers,II: How consumers can find cost-effective,quality health care

The original "Searchers" article appeared in the March 2000 issue of Employee Benefits Journal. It described the use of a patient satisfaction survey at Southwest Texas State University (SWT) to assist employees at the annual open enrollment period to better select their managed care organization (MCO). This article revisits that process, but further describes the subsequent publication of a recommended list of preferred physicians and the use of the peer review to report consumer concerns about the performance of individual physicians.     

Evaluation of a client care delivery model, Part 2: Variability in client outcomes in community home nursing

Using similar variables, Part II explores variation in client outcomes such as OMAHA knowledge, behavior, and SF-36 scores. Medical and nursing diagnoses explained large variations in client outcomes. Clients cared for by degree-prepared nurses improved knowledge and behavior scores. Unanticipated case complexity was negatively associated with client outcome even with nursing intervention. The study revealed that "for every unit increase in assignment of baccalaureate-prepared nurses, clients will on average demonstrate an 80% greater likelihood of improvement in knowledge scores and a 120% greater likelihood of improvement in behavior scores in relation to their health condition at discharge." This two-part study has offered insight into the controllable variables influencing the cost and quality of home care services.     

The CNO/CFO partnership: navigating the changing landscape

With increasing pressure to cut costs, both real and immediate, and those forecasted and anticipated, the partnership and collaboration between nursing and finance will continue to take on new challenges. This partnership has historically been strained and does not always come easy due to differences in focus, different priorities, and inadequate communication, listening, and hearing. That needs to change and a strong CNO-CFO partnership is needed. Nursing leaders need to understand and appreciate the financial constraints and balance them with expected outcomes, and financial leaders need to understand and appreciate the core clinical business and what gaps in care mean to the financial viability of the organization and to patient outcomes. One health system developed a platform for change and is dedicated to the hard work involved in continuously working on those partnerships so when it comes to patient quality, safety, and financial performance, nursing and finance leaders are well positioned for future health care challenges.     

The relationship of the hospital-acquired injurious fall rates with the quality profile of a hospital's care delivery and nursing staff patterns

Fall occurrence during hospital stays is a well-recognized nursing-sensitive outcome indicator. This study was intended to determine the unique contributions of three inpatient satisfaction measures on the hospital-acquired injurious fall rates. Study results demonstrated the higher the inpatient satisfaction levels with the quietness of hospital environment, the lower the injurious fall rates. The physical environment (quietness) of the acute inpatient care settings was a significant and meaningful determinant of the prevalence of injurious falls. Additionally, more total nursing personnel FTEs per 1,000 discharges and a higher percentage of RN FTEs by total nursing personnel FTEs would not result in better patient outcomes.     

试析人文关怀在病患输液过程中的作用

目的 探讨人文关怀在病患输液过程中的临床应用价值.方法 选取2010年7月至2012年9月来我院接受静脉输液治疗的患者89例,44例患者采用常规护理方法进行护理,作为对照组,45例患者在常规护理的基础上采用人文关怀模式进行护理,作为观察组,分别以两组患者的护理满意程度作为临床观察指标,并使用SPSS软件包进行统计学分析.结果 观察组患者的护理满意度明显高于对照组患者,P＜0.01.结论 在常规护理的基础上采用人文关怀模式可有效提高患者输液过程中的护理满意度,对于提高患者的治疗效果具有重要的意义.     

Nursing overtime: why, how much, and under what working conditions?

To provide the best care to patients, the physical wellness of nursing staff is essential. Current evidence indicates long work hours can lead to adverse nurse and patient outcomes. To provide quality and safe patient care, both staff nurses and nurse managers need to recognize the adverse effects of overtime, whether it is mandatory or voluntary. Results of this study showed overtime was not used more when there was an increase in nursing shortages. Further, overtime was not used to control shortages; rather, understaffing was an underlying condition of the nursing practice, at least in the study sample. Thus, efforts must be made not only to prevent nurses from working long hours, but also to resolve the problem of understaffing in order to retain qualified nurses in hospitals.     

Nursing home costs and quality of care outcomes

The relationship between cost and quality of care in nursing homes was examined using quality indicator measures of resident outcomes. While each individual quality measure makes only small contributions to costs, when considered across the facility, quality could have a substantial financial impact on the operations of the home.     

Cost-effectiveness of mechanical thrombectomy for acute ischemic stroke: an Australian payer perspective

Aims: The goal of this study was to assess the cost-effectiveness of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) from an Australian payer perspective.

Methods: This study used a Markov model that employed a life-time time horizon, modeling patients from symptom onset of stroke until end of life. Clinical efficacy and safety data were taken from an individual patient level data (IPD) meta-analysis of clinical studies. The treatment effect of MT compared to usual care was measured by changes in modified Rankin Score (mRS). Post-treatment mRS scores were used to determine short- and long-term stroke care costs. Treatment costs were modeled, with health state utility values determined by literature review. All analyses were conducted using Microsoft Excel.

Results: In comparison to usual care, MT is associated with higher costs ($10,666 per patient) and additional quality-adjusted life years (QALYs) (0.8281 per patient), resulting in an incremental cost per QALY of $12,880. Sensitivity analyses demonstrated the reliability of the base case results across a range of assumptions. The higher cost associated with MT is, to an extent, offset by the cost savings resulting from lower stroke care costs due to improved patient outcomes. The life-time cost savings in terms of stroke care costs are estimated to be more than $8,000 per patient for patients who had received MT in combination with usual care.

Limitations: Stroke care costs based on patient disability/functional level were not available and were derived. As a consequence, long-term care costs for patients with poorer outcomes may be under-estimated. Patient outcomes at 90 days were extrapolated to a lifetime horizon, but this approach was supported by long-term evidence on stroke survival.

Conclusions: Mechanical thrombectomy is a cost-effective treatment option for AIS, with clinical benefits translating to short- and long-term cost benefits. This analysis supports rapid update of stroke care pathways to incorporate this therapy as a treatment option.     

QUALITY CHOICE AND MARKET STRUCTURE: A DYNAMIC ANALYSIS OF NURSING HOME OLIGOPOLIES

This article develops a dynamic model of entry and exit to analyze quality choice and oligopoly market structure in the nursing home industry. I find significant heterogeneity in the competitive effects across market structures: Firms of similar quality levels compete more strongly than dissimilar firms. Sunken entry costs are extremely large, and quality adjustment behavior is governed by significant fixed adjustment costs. A proposal to eliminate low‐quality nursing homes is found to cause a large supply‐side shortage, and another proposal to lower entry costs has offered a perverse incentive to provide low quality of care.     

Hospital nursing costs, billing, and reimbursement

Nursing intensity, estimated direct nursing costs, and daily billing were compared for 12 adult medical or surgical units at an academic medical center from January 1 to May 31, 2005 (22,649 patient days). Two main findings, nursing intensity and direct nursing costs, were highly variable within and across each of the study nursing units (mean 429 dollars, SD 160 dollars); direct costs of nursing care were significantly higher for private room rates compared to intermediate room per diem charges billed at a higher rate (441 dollars vs. 426 dollars, F 37.77, p < 0.001). The results demonstrate that the direct costs of nursing care are not aligned with current billing practices at this university hospital. The use of fixed room and board charges to account for nursing care in U.S. hospitals may be obsolete and an alternative nurse-centric costing, billing, and reimbursement model is proposed.     

The impact of nursing on patient and organizational outcomes

The impact of nursing on patient and organizational outcomes has received significant attention from researchers in the past 10 years. Although some research has been based on a theoretical framework, to date, there has not been one, consistent framework that can guide this research. In addition, the frameworks that have been used do not identify nursing as the pivotal concept in the model. The purpose of this article is to identify a framework to guide such research with an emphasis on nursing as the essential concept. Unit culture, nurse staffing, staffing mix, and other variables do not have a direct effect on outcomes. It is only through these variables' influence on the delivery of nursing care that outcomes are affected.     

结核性脓胸围术期护理研究

目的：探讨结核性脓胸围术期护理效果。方法选取我院收治的结核性脓胸患者211例,将其按照随机数字法分为观察组和对照组,对照组患者给予常规护理,观察组患者给予围术期护理,比较两组患者的护理效果。结果观察组患者并发症发生率低,患者满意程度高,明显优于对照组（P＜0.05）。结论对结核性脓胸患者实施围术期护理,可有效减少并发症的发生率,提高患者及家属对护理服务的满意度。     

The importance of measuring patient satisfaction

Managed care has demonstrated its ability to contain costs. Its emergence as a dominant factor in the health care marketplace has raised concerns about measuring health care quality. As the field of quality assurance is evolving, it is becoming clearer that patient satisfaction surveys should be an integral component of assessing care.