Diabetes and hypertension quality measurement in four safety-net sites: lessons learned after implementation of the same commercial electronic health record.

BACKGROUND: In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. OBJECTIVES: Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. METHODS: A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. RESULTS: While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. CONCLUSIONS: Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care delivery models.

Development of an academic consortium for nurse-managed primary care.

This article describes the development of an academic consortium comprised of four universities and their schools and colleges of nursing. The initial efforts at collaboration arose from the need to obtain funding and address policy issues related to advanced practice issues at the state level. The developmental stages of the Michigan Academic Consortium are described within a framework developed by Bailey and Koney (I).

Smoking cessation and low-income women: theory, research, and interventions.

There is a growing body of evidence indicating women's experiences with smoking and cessation may be unique from those of men. Advanced practice nurses (APNs) in primary care are ideally suited to assess and intervene with this complex addiction. APNs must be competent in interventions that address cigarette smoking. This article will summarize the literature on smoking cessation interventions with an emphasis on women smokers.

Longitudinal employment decisions of daughters and daughters-in-law after assuming parent care.

Employment decisions of full-time, part-time and not employed daughters and daughters-in-law (n = 157) are described over the first 18 months of parent care at two points in time: three months after assuming care and 15 months later. Employment decisions were also examined when caregiving continued (n = 55), when it was discontinued (n = 55) and when a parent died (n = 47). Findings indicate that part-time employed daughters make more changes and adjustments in their employment than do full-time or not employed daughters. When a parent died, more changes in employment occurred prior to the death than when a parent remained in care.

Predictors of participation in a smoking cessation intervention group among low-income women.

The predictors of participation in a smoking cessation group among low-income women were examined. Fifty smokers were recruited from a Midwestern community primary care setting serving an uninsured, underinsured, and Medicaid population. Participants completed a questionnaire before the intervention, and eleven women chose to participate in the 6-week sessions. There were few differences between the control group (nonparticipants) and the intervention group. The intervention group had significantly higher intention-to-quit scores. Logistic regression analysis was used to predict group membership with age, self-efficacy, optimism, social support, nicotine dependence, intention-to-quit, and other smokers in the home as the predictor variables. The only two significant predictors of participation in the cessation intervention were self-efficacy and intention-to-quit smoking. The higher the intention-to-quit score and the lower the self-efficacy score (the belief that one can be successful in not smoking); the more likely these women were to participate in the group intervention. Results are discussed in terms of their clinical relevance as well as future research in the area.

Smoking cessation: using group intervention methods to treat low-income women.

Cigarette smoking, the leading cause of preventable death in the United States, has become an increasing concern for women. Women's smoking prevalence will soon surpass men's, and the tobacco industry continues to target women in its advertising campaigns. This article presents findings from a descriptive study, including the development, implementation, and evaluation of a group intervention designed for low-income women and conducted in an urban primary care clinic. Of the 55 female smokers who agreed to complete a smoking questionnaire, nine completed the 6-week program led by two nurse practitioners. The women smoked an average of 22.7 cigarettes/day at the start of the program and 9.2 cigarettes/day at its conclusion. Of the nine women, eight moved from the precontemplation stage to preparation, and all nine quit smoking for at least 1 month during the first months after the intervention. Group intervention is presented as an effective method of smoking intervention for providers in primary care.

Analysis of the impact of mother-daughter relationships on the commitment to caregiving.

Path analysis was used to test a model to examine the impact of mother-daughter relationships on the commitment to caregiving by 98 adult daughters during the first three months. Findings generally supported the model. Although significant, magnitude of mothers' limitations did not solely explain commitment, either instrumental or affective. Mother-daughter relationships were powerful predictors of commitment, especially affective commitment. Although predicted, employment status did not function as a mediator in this model, while living arrangements did.

Beyond patient dependency: family characteristics and access of elderly patients to home care services following hospital discharge.

Access to Skilled Nursing and Home Health Aid services among elderly patients (N = 580) and their family caregivers post hospital discharge was examined using logistic regression. A majority of the sample (65%) were referred for Skilled Nursing services while only 28% were referred for Home Health Aid services. Caregiving situations in which the spouse was the primary caregiver were less than half as likely to be referred for either service when compared to non-spouses. As expected, ADL limitations were a significant predictor of referral for both services. Women patients with the same ADL limitation as men were only about a fourth as likely to be referred for Home Health Aid services as men. Findings are discussed in terms of access to care and the need for policy to consider more than patient limitations in the referral criteria.

Social vulnerability and reactions to caregiving in daughters and daughters-in-law caring for disabled aging parents.

Variables that have been conceptually linked with social vulnerability--income, educational level, employment, cessation of work to provide care, marital status, social support, and health--were used to predict four categories of reaction to caregiving in 159 daughters and daughters-in-law caring for their disabled aging parents. Social support, income, and health best predicted negative reactions to caregiving; social support alone best predicted negative reactions to caregiving; social support alone best predicted feelings of family abandonment, impact on health, and impact on schedule. Compared with daughters and daughters-in-law who had not quit work to provide care, those who had quit work were significantly older, had lower incomes and fewer social supports, and were more involved in care. The results suggest that quitting work may be a precursor to social isolation that places the caregiver at increased risk for social vulnerability and negative reaction to caregiving. The implications of the findings for health care policy are discussed.

Ageism within feminism.

Recently there has been heightened interest in linking feminist theory and nursing science. However, neither feminists nor feminist nursing scholars have included aging women in their analyses. This paper analyzes liberal, radical and socialist feminist theories and discusses the gap within all three vis-a-vis aging women. A case is presented for including aging women within feminist thinking and recommendations for incorporating feminist theory and aging within the science of nursing are explicated.

Cancer screening practices of nurse practitioners.

The Nurse Practitioner's (NP) role in providing quality primary care with emphasis on health promotion is well established. Yet the NP's actual cancer detection activities are unknown. To determine the cancer screening and detection activities of NPs in adult primary care settings, a questionnaire survey was developed from the American Cancer Society's "Guidelines for the Cancer-Related Checkup" and current cancer detection literature. The survey was distributed to primary care NPs throughout the state of Michigan (n = 97). Pearson correlation coefficients were applied to the data to establish the relationship of cancer screening practices by NPs to specific age groups and by gender. Practitioners reported significantly higher frequencies of recommended screening for adult women than for adult men. Although at a lower risk for developing cancer, younger and early middle-aged adults (19-39 years) received significantly higher frequencies of recommended screening than middle-aged and older adults. NPs believe that cancer screening and counseling are consistent with their role except in the areas of male physical exam (testes, prostate) and invasive procedures such as sigmoids for men and women. The broader implications for further research, organization of primary care services, and strategies to increase nurses' involvement in cancer screening practices are presented.

Perceived choice, social interaction, and dimensions of moral of residents in a home for the aged.

In a study of 50 residents in a home for the aged, the relationships of health at relocation, choice in relocation, income, perceived choice within an institutional environment, and social interaction to four indices of morale were examined in hierarchical multiple regression designs. The theoretical concept of decisional control (i.e., perceived choice) guided the investigation. Significant multivariate effects were found for all dimensions of morale: agitation, attitude toward own aging, lonely dissatisfaction, and a combined morale index. Choice within the institution and social interaction were the major contributors to these significant multivariate relationships, but income was also influential in analysis of the attitudinal and combined morale indices for a subsample. Retrospective measures of health at relocation and choice in relocation were unstable in their contributions to overall multivariate relationships. Relationships of age, recency of loss of a significant other, and length of residency to morale were explored and found not to be significant. Results are discussed against the background of theoretical expectations, and avenues for future research are identified.