The marketability of nurse practitioners in New York City

Until recently nurse practitioners (NPs) in independent practices have almost exclusively served Medicaid populations, and, most NP care has been provided by NP employees in physicians' offices or HMOs. The author explores the willingness of affluent or insured private pay patients to choose NPs as their primary care providers by using both focus groups and telephone interviews of adults between 25 and 50 years of age. Findings included the common perception that physicians were best prepared by education at diagnosing illness and valued for their overall expertise and likelihood to treat patients with respect. Nurses were most liked for their "compassion and caring," their willingness to listen to client concerns, and focus on disease management and health promotion. Nurses were least liked for having "bad attitudes" and being overworked. Only 23% of the survey participants were familiar with the term "advanced practice nurse" while 76% had heard of NPs.     

Crossing the quality chasm: creating the ideal patient care experience

To create a health system that better meets patients' needs requires a fundamental redesign of our care delivery system and a new framework. Without a payment mechanism to reflect the value of care provided other than the face-to-face visit, adoption of advanced medical home principles will be challenging. The hand-off of the patient between providers and settings of care is a critical time for the patient and its effectiveness impacts patient care outcomes. The appropriate utilization of hospital and other health system resources is crucial, especially as hospitals, emergency departments, and other health care venues increasingly face capacity constraints and throughput challenges. It becomes the responsibility of the multidisciplinary team of providers to ensure that patients being discharged have an identified personal physician or team who will provide a medical home, and that the handoff to this medical home is thorough and well coordinated. An ideal patient care experience is one in which all systems and processes are geared to meet the needs of the patient: a safety-oriented system that provides standardized, evidence-based care supported by technology, but that recognizes and responds to individual needs.     

How can nurses help patients work more effectively with nurses to improve the safety of patient care?

The literature seems quite clear that patients still regard the nurse as the principal link between the technical and interpersonal aspects of their care. The often-discussed medical error crisis tends to create in the patient mistrust of all care providers. The health care industry is driving towards a system that requires patients to be self-reliant in managing their care, without allowing for factual limitations in patient capability, ability, and interest in such an enterprise. Unfortunately for the overworked, understaffed nurse, patients still look to them to provide quality compassionate care without the patient having to police them. Health care providers have been mandated to provide assessment and intervention for pain management. It was mandated because we as health care professionals failed to perform this vital function in a consistent, quality manner. It did add to the workload of the nurse. However, if done properly, it is a valuable communication tool for the nurse and the patient to comfortably discuss pain and its management--the interpersonal part of care.     

An innovative role for nurse practitioners in managing chronic disease

Under the current care delivery model, persons with chronic illnesses, such as diabetes, are not receiving all recommended interventions and failing to meet targeted outcomes. The Chronic Care Model provides a framework for new approaches and roles for many members of the multidisciplinary team. Using the Chronic Care Model as a guide, a group of hospital-based clinics in an academic system incorporated nurse practitioners into the care model for patients with diabetes. Through use of planned visits, a patient registry, drug intensification protocols, and collaboration with other members of the team, the pilot sample improved processes of care and clinical outcomes. Use of nurse practitioners in this model of care for chronically ill patient populations has economic implications, as the payers begin to pay for performance.     

Ambulatory care nursing: growth as a professional specialty

Ambulatory care nursing has emerged as a distinct professional nursing specialty. Many characteristics differentiate ambulatory care nursing from other specialty practices, including the settings, the characteristics of the patient encounters and the focus upon groups, communities, and populations, as well as individual patients and their families. A conceptual framework for ambulatory care nursing was developed in 1998 and recently revised, through consensus of leaders in the specialty. The key elements of the Ambulatory Care Nursing Conceptual Framework are the patient, the environment (both internal and external), and the nurse, practicing in three major roles.     

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.     

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.     

Expanded role of nursing in ambulatory managed care. Part II: Impact on outcomes of costs, quality, provider and patient satisfaction

This evaluation project used a triangulation of methods and data sources to link the expanded role nurse clinician (NC) to outcomes of costs, quality, and satisfaction in managed care. Results of patient surveys, case studies, cost-benefit analyses, interviews, focus groups, and HMO documents suggest that the impact of the role has benefit far beyond its costs. This article builds on an earlier article (Nursing Economic$, Vol. 17, No. 1). Part I reviewed literature on expanded role nursing in population management, and described the development of the NC role. In Part II, the NC expanded role is linked to organizational outcomes of costs, quality, and satisfaction. Results here could be used by managers and planners to provide rationale for implementing expanded nursing roles in managed care in order to improve ambulatory care processes, recruit and retain nurses, reduce costs, and increase patient and provider satisfaction.     

The implications of nurse staffing information: the real value of reporting nursing data

There is a dearth of information about the relationship between the patient care contributions of nursing and its financial contributions to an organization. As consumers and legislators are becoming more aware of the ramifications of nurse staffing issues, and as they endeavor to address them with legislative solutions, the decision on how best to develop optimal staffing strategies may soon be taken away from nursing leaders. To maintain control of this important issue and develop solutions that will help highlight the economic and patient care contributions of nurses, a thorough understanding of the problem, and a new commitment are needed from nursing leaders to take charge of the issue. To relate nursing care to patient outcomes, meaningful data on the nursing care provided is needed in addition to data on the nursing needs of patients. Staffing and performance monitoring tools should be used to effectively plan, implement, and control financial and operating resources as well as measure the economic value of the nursing profession's contribution to the cost and benefits of patient care.     

Cost of health care and quality outcomes of patients at nurse-managed clinics

Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nurse-managed clinics are to remain viable.     

Insurer policies create barriers to health care access and consumer choice

A national survey shows that most insurance companies refuse to credential nurse practitioners in nurse-managed health centers as primary care providers. These prohibitive policies along with weak federal and state laws threaten the long-term sustainability of nurse-managed health centers as safety net health care providers, and the ability for nurse practitioners to become an accepted primary health care source in the United States.     

The language of business: a key nurse executive competency

The ability to interpret fiscal data pertaining to patient outcomes, human resources, customer satisfaction, and financial positions is a vital evidenced-based nurse executive competency. The ability of nurse leaders to influence and contribute in health system executive decision making requires fluency in accounting, "the language of business." After examining challenges faced by nurse executives, faculty at the Loewenberg School of Nursing at the University of Memphis integrated intensive accounting education into a new executive MSN program. Woven throughout the management accounting course is the concept that accounting data must be relevant and accurate for use by organization decision makers. Evidence-based decision making is emphasized when teaching planning and control activities. In addition, fluency in accounting is enhanced which leads to greater skill in patient and nursing advocacy. As competency in management accounting increases through the semester, executive MSN students are encouraged to apply cost accounting course content to their practice settings and to analyze how planning or control activities improve quality outcomes.     

Outcomes from use of an evidence-based practice guideline

The aim of evidence-based guidelines is primarily to improve patient outcomes without adding to the existing cost of care because both payers and policymakers want to identify health care costs that do not result in benefit to the patient. The purpose of the reported project was to generate a practice guideline for the treatment of uncomplicated acute cystitis in a female population, to determine the extent to which the guideline would be used by providers and to measure the cost and quality of outcomes from its use. A retrospective chart review was used to gather pre-guideline practice and cost data. Measurements included the type, frequency, and duration of antibiotic therapy and the use of urine cultures and both complications and routine followup visits. The implementation of an outpatient practice guideline resulted in a significant change in antibiotic prescribing and a trend toward a change in ordering cultures and clinic followup. There was also a significant decrease in treatment costs.     

The legal challenge to ERISA preemptions

Managed care, once celebrated as a vehicle to halt the increasing cost of health care, has come under increasing fire from patients and health care providers, accused of cutting costs and managing care at the expense of patients. The Employee Retirement Income Security Act of 1974 (ERISA) has been a shield for managed care organizations (MCOs), buffeting them from liability for quality-of-care issues. Lawsuits and legislation are chipping away at the protective shield of ERISA as MCOs find themselves more liable for their decisions and for the care provided by physicians with whom the MCO contracts and provides financial incentives for controlling cost of medical care.     

Using diagnostic clusters to evaluate patterns of treatment and develop capitation rates

Payers and providers of medical services need to understand what is effective in medical care and what determines patient outcomes. The diagnostic cluster methodology offers a way to analyze physicians' overall practice patterns in treating a specific medical condition and provides a good foundation for performing medical outcomes studies.     

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.     

Staff nurse financial management committees--the nurse manager's guide to effective financial performance

As Cohen states (1991, p. 25), "The future role that nursing will play in the health care delivery system is one of many major issues faced by contemporary nursing...Nursing must be able to determine realistically the cost of and evaluate the effectiveness of nursing care provided to its patients." A unit-based financial management committee is one very effective way of teaching the skills needed for the professional nurse to advance the practice in financial management. This will help nursing gain the professional status that they have always worked for. But beyond these very lofty ideals, a staff nurse managed financial management committee can make the nurse manager's life much easier. Staff nurses need to understand and accept the importance of managing the financial as well as the quality side of patient care. When this happens, the budget becomes theirs. Nurses develop a sense of ownership of the budget and learn how to effectively manage the unit's finances. Much staff nurse brain power is not used. Systems must be developed to access nurses' effective ideas for financial management--first in a financial management committee and then on the unit. Not only will this develop the professional status that nurses need and deserve, but it will also impact the cost of health care. In a society where the cost of an appendectomy requires Dayton Hudson to sell 39,000 Ninja Turtle action figures, Atlantic Richfield to sell 192,000 gallons of gas a day, Anheuser-Busch to sell 11,627 6-packs of 12 oz.(ABSTRACT TRUNCATED AT 250 WORDS)     

What role can nurse leaders play in reducing the incidence of pressure sores?

Pressure sores have plagued the nursing profession for many years as a major health care problem in terms of a patient's suffering and financial cost. Pressure sores are increasingly common in hospitalized patients in the United States with a 63% increase from 1993 to 2003. The nurse leader is accountable for the occurrence of pressure sores, a nurse-sensitive indicator, by a scorecard which is benchmarked against other facilities. The nurse leader must take a systematic approach in the prevention of pressure sores, with the strategy being consistent and motivating to the staff in order to improve patient outcome. The chief nursing officer, the unit manager, and the bedside nurse must all collaborate to prevent tissue injury in patients at risk for developing pressure sores and to promote wound healing in patients with existing breakdown.     

Cost-effective care a phone call away: a nurse-managed telephonic program for patients with chronic heart failure

Health care providers and health care systems are challenged to find cost-effective ways to address the costs associated with heart failure. A multidisciplinary team of nurses, physicians, pharmacists, and dieticians was assembled at New Hanover Regional Medical Center (Wilmington, NC) to develop strategies to decrease the readmission rate without compromising patient care. The team developed a disease management program that included comprehensive inpatient education, as well as an outpatient telephonic program to reinforce education after discharge. Goals were to reduce readmissions of patients with heart failure, to decrease the cost per case of each patient with chronic heart failure, and to reduce the length of stay for patients who were readmitted. The CHF Telephonic Program was extremely successful in meeting patient-focused and organizational goals related to readmissions, length of stay, and cost of care.