Effect of Discharge Readiness on 30-Day Readmissions Among Older Adults Living With Multiple Chronic Conditions.

BACKGROUND: Despite decreases in readmissions among Medicare beneficiaries after the implementation of the Hospital Readmissions Reduction Program, older adults living with multiple chronic conditions (MCCs) continue to experience higher readmission rates. Few strategies leverage nursing to identify patients at risk for readmission. OBJECTIVES: Examine the effect of nurse assessments of discharge readiness on 30-day readmissions. RESEARCH DESIGN: Cross-sectional study linking 3 secondary data sources (ie, nurse survey, hospital survey, and Medicare claims data) representing 424 hospitals. SUBJECTS: A total of 188,806 Medicare surgical patients with MCCs. MEASURES: Discharge readiness was derived from the 2016 RN4CAST-US survey. Medicare claims data was used to determine the MCC count. The outcome was 30-day readmissions across the MCC count. RESULTS: The average discharge readiness score was 0.45 (range=0-0.86) indicating that, in the average hospital, <50% of nurses were confident their patient or caregiver could manage their care after discharge. Nearly 8% of patients were readmitted within 30 days of discharge; the highest rates of readmissions were among individuals with ≥5 MCCs (4293, 13.50%). For each 10% increase in the proportion of nurses in a hospital who were confident in their patients' discharge readiness, the odds of 30-day readmission decreased by 2% (95% CI: 0.96-1.00; P =0.028) for patients with 2-4 MCCs and 3% (95% CI: 0.94-0.99; P =0.015) for patients with ≥5 MCCs, relative to patients with 0-1 MCCs. CONCLUSIONS: Nurse assessments of discharge readiness may be a useful signal for hospitals to reduce readmissions and examine factors interfering with discharge processes.

The Impact of Primary Care Practice Structural Capabilities on Nurse Practitioner Burnout, Job Satisfaction, and Intent to Leave.

BACKGROUND: Lack of structure for care delivery (ie, structural capabilities) has been linked to lower quality of care and negative patient outcomes. However, little research examines the relationship between practice structural capabilities and nurse practitioner (NP) job outcomes. OBJECTIVES: We investigated the association between structural capabilities and primary care NP job outcomes (ie, burnout, job dissatisfaction, and intent to leave). RESEARCH DESIGN: Secondary analysis of 2018-2019 cross-sectional data. SUBJECTS: A total of 1110 NPs across 1002 primary care practices in 6 states. MEASURES: We estimated linear probability models to assess the association between structural capabilities and NP job outcomes, controlling for NP work environment, demographics, and practice features. RESULTS: The average structural capabilities score (measured on a scale of 0-1) across practices was 0.6 (higher score indicates more structural capabilities). After controlling for potential confounders, we found that a 10-percentage point increase in the structural capabilities score was associated with a 3-percentage point decrease in burnout ( P <0.001), a 2-percentage point decrease in job dissatisfaction ( P <0.001), and a 3-percentage point decrease in intent to leave ( P <0.001). CONCLUSIONS: Primary care NPs report lower burnout, job dissatisfaction, and intent to leave when working in practices with greater structural capabilities for care delivery. These findings suggest that efforts to improve structural capabilities not only facilitate effective care delivery and benefit patients but they also support NPs and strengthen their workforce participation. Practice leaders should further invest in structural capabilities to improve primary care provider job outcomes.

Primary Care Practice Structural Capabilities and Emergency Department Utilization Among High-Need High-Cost Patients.

BACKGROUND: US primary care practices are actively identifying strategies to improve outcomes and reduce costs among high-need high-cost (HNHC) patients. HNHC patients are adults with high health care utilization who suffer from multiple chronic medical and behavioral health conditions such as depression or substance abuse. HNHC patients with behavioral health conditions face heightened challenges accessing timely primary care and managing their conditions, which is reflected by their high rates of emergency department (ED) utilization and preventable spending. Structural capabilities (i.e., care coordination, chronic disease registries, shared communication systems, and after-hours care) are key attributes of primary care practices which can enhance access and quality of chronic care delivery. OBJECTIVE: The purpose of this study was to analyze the association between structural capabilities and ED utilization among HNHC patients with behavioral health conditions. DESIGN AND MEASURES: We merged cross-sectional survey data on structural capabilities from 240 primary care practices in Arizona and Washington linked with Medicare claims data on 70,182 HNHC patients from 2019. KEY RESULTS: Using multivariable Poisson models, we found shared communication systems were associated with lower rates of all-cause and preventable ED utilization among HNHC patients with alcohol use (all-cause: aRR 0.72, 95% CI: 0.62, 0.84; preventable: aRR 0.5, 95% CI: 0.40, 0.64) and HNHC patients with substance use disorders (all-cause: aRR 0.76, 95% CI: 0.68, 0.85; preventable: aRR 0.61, 95% CI: 0.52, 0.71). Care coordination was also associated with decreased rates of ED utilization among the overall HNHC population and those with alcohol use, but not among HNHC patients with depression or substance use disorders. CONCLUSION: Shared communication systems and care coordination have the potential to increase the effectiveness of primary care delivery for specific HNHC patients.

Using machine-learning methods to predict in-hospital mortality through the Elixhauser index: A Medicare data analysis.

Accurate in-hospital mortality prediction can reflect the prognosis of patients, help guide allocation of clinical resources, and help clinicians make the right care decisions. There are limitations to using traditional logistic regression models when assessing the model performance of comorbidity measures to predict in-hospital mortality. Meanwhile, the use of novel machine-learning methods is growing rapidly. In 2021, the Agency for Healthcare Research and Quality published new guidelines for using the Present-on-Admission (POA) indicator from the International Classification of Diseases, Tenth Revision, for coding comorbidities to predict in-hospital mortality from the Elixhauser's comorbidity measurement method. We compared the model performance of logistic regression, elastic net model, and artificial neural network (ANN) to predict in-hospital mortality from Elixhauser's measures under the updated POA guidelines. In this retrospective analysis, 1,810,106 adult Medicare inpatient admissions from six US states admitted after September 23, 2017, and discharged before April 11, 2019 were extracted from the Centers for Medicare and Medicaid Services data warehouse. The POA indicator was used to distinguish pre-existing comorbidities from complications that occurred during hospitalization. All models performed well (C-statistics >0.77). Elastic net method generated a parsimonious model, in which there were five fewer comorbidities selected to predict in-hospital mortality with similar predictive power compared to the logistic regression model. ANN had the highest C-statistics compared to the other two models (0.800 vs. 0.791 and 0.791). Elastic net model and AAN can be applied successfully to predict in-hospital mortality.

Advancement of research on nurse practitioners: Setting a research agenda.

BACKGROUND: Primary care delivered by nurse practitioners (NPs) helps to meet the United States' growing demand for care and improves patient outcomes. Yet, barriers impede NP practice. Knowledge of these barriers is limited, hindering opportunities to eliminate them. PURPOSE: We convened a 1.5-day conference to develop a research agenda to advance evidence on the primary care NP workforce. METHODS: Thirty experts gathered in New York City for a conference in 2022. The conference included plenary sessions, small group discussions, and a prioritization process to identify areas for future research and research questions. DISCUSSION: The research agenda includes top-ranked research questions within five categories: (a) policy regulations and implications for care, quality, and access; (b) systems affecting NP practice; (c) health equity and the NP workforce; (d) NP education and workforce dynamics, and (e) international perspectives. CONCLUSION: The agenda can advance evidence on the NP workforce to guide policy and practice.

The Growing Primary Care Nurse Practitioner Workforce: A Solution for the Aging Population Living With Dementia.

Redesigning the healthcare workforce to meet the needs of the growing population of persons living with dementia (PLWD), most of whom reside in the community and receive care from primary care providers, is a national priority. Yet, the shortage of adequately trained providers is raising concerns that the primary care system is not equipped to care for PLWD. The growing nurse practitioner (NP) workforce could bridge this gap. In this review, the authors synthesized the existing evidence from fourteen studies on the utilization of NPs to care for PLWD in primary care. Although the authors found that most NPs were engaged in co-management roles, emerging evidence suggests that NPs also serve as primary care providers for PLWD. Findings describe the impact of NP care on the health system, PLWD, and caregiver outcomes. The authors conclude that the optimal utilization of NPs can increase the capacity of delivering dementia-capable primary care.

Why Some Nurses Obtain Specialty Certification and Others Do Not.

OBJECTIVE: The aim of this study was to determine whether there are modifiable characteristics of nurses and hospitals associated with nurse specialty certification. BACKGROUND: Hospitals, nurses, and patients benefit from nurse specialty certification, but little actionable evidence guides administrators seeking higher hospital certification rates. METHODS: This is a cross-sectional, secondary data analysis of 20 454 nurses in 471 hospitals across 4 states. RESULTS: Rates of certified nurses varied significantly across hospitals. Higher odds of certification were associated with Magnet® recognition and better hospital work environments at the facility level, and with BSN education, unit type (most notably, oncology), older age, more years of experience, and full-time employment at the individual nurse level. CONCLUSION: Two strategies that hold promise for increasing nurse specialty certification are improving hospital work environments and preferentially hiring BSN nurses.

System-Level Improvements in Work Environments Lead to Lower Nurse Burnout and Higher Patient Satisfaction.

BACKGROUND: Burnout among nurses is associated with lower patient satisfaction, yet few system-level solutions have been identified to improve outcomes. PURPOSE: The purpose of this study was to examine the relationship between nurse burnout and patient satisfaction and determine whether work environments are associated with these outcomes. METHODS: This study was a cross-sectional analysis of 463 hospitals in 4 states. Burnout was defined using the Maslach Burnout Inventory. Patient satisfaction was obtained from the Hospital Consumer Assessment of Healthcare Providers and Systems survey. RESULTS: Fifty percent of hospitals where burnout is high have poor work environments, which is strongly related to lower patient satisfaction. CONCLUSIONS: High levels of nurse burnout are associated with lower patient satisfaction. Our findings demonstrate that hospitals can improve outcomes through investments in work environments.

Quality of End of Life Care in Magnet® and Non-Magnet Hospitals.

OBJECTIVE: To examine whether end-of-life care quality is superior in Magnet hospitals, a recognition designating nursing excellence. BACKGROUND: Considerable research shows better patient outcomes in hospitals with excellent nurse work environments, but end-of-life care quality has not been studied in Magnet hospitals. METHODS: An analysis of cross-sectional data was completed using surveys of nurses and hospitals. Multivariate logistic regression models were used to determine the association between Magnet hospitals and measures of end-of-life care quality. RESULTS: Overall, nurses report poor quality of end-of-life care in US hospitals. In Magnet hospitals, nurses were significantly less likely to give their hospital an unfavorable rating on end-of-life care. CONCLUSIONS: Hospital Magnet status may signal better quality in end-of-life care. Administrators looking to improve the quality of end-of-life care may consider improving aspects of nursing that distinguish Magnet hospitals.

Primary Care Organizational Support for Nurse Practitioner Practice and Emotional Health Care Delivery.

OBJECTIVES: Nurse practitioners (NPs) are key to delivery of primary care services. However, poor organizational support for independent NP practice, such as lack of access to clinic resources, may lead to prioritizing patient physical health over emotional health. We investigated the relationship between organizational support for independent NP practice and emotional health care delivery. METHODS: This was a secondary analysis of cross-sectional survey data collected from 397 NPs in 2017. We measured organizational support for independent NP practice using the independent practice and support subscale of the NP Primary Care Organizational Climate Questionnaire. Emotional health care delivery was measured by asking NPs how frequently they addressed emotional concerns of patients. We utilized multilevel mixed effects linear regression models, adjusting for NP and practice covariates. RESULTS: Controlling for NP age, gender, marital status, race, and ethnicity, along with practice setting and size, as the independent practice and support score increased, NPs reported addressing emotional concerns of patients more frequently (beta = 0.34, 95% confidence interval = 0.02-0.66, P = 0.04). This indicates that as organizations provided more support for independent NP practice, NPs were able to more frequently address emotional concerns of patients. CONCLUSIONS: Organizational support for independent NP practice is associated with addressing emotional concerns of patients. To support NP practice, primary care organizations should ensure that NPs manage patients independently and have access to ancillary staff and support for care management.

A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions.

Multiple chronic conditions (MCCs) are more common and costly than any individual health condition in the United States. The growing workforce of nurse practitioners (NPs) plays an active role in providing primary care to this patient population. This study identifies the effect of NP primary care models, compared with models without NP involvement, on cost, quality, and service utilization by patients with MCCs. We conducted a literature search of six databases and performed critical appraisal. Fifteen studies met inclusion criteria (years: 2003-2021). Overall, most studies showed reduced or similar costs, equivalent or better quality, and similar or lower rates of emergency department use and hospitalization associated with NP primary care models for patients with MCCs, compared with models without NP involvement. No studies found them associated with worse outcomes. Thus, NP primary care models, compared with models without NP involvement, have similar or positive impacts on MCC patient outcomes.

The Association between Primary Care Practices' Structural Capabilities and Hospitalizations among Persons Living with Dementia.

Background: Persons living with dementia (PLWD) are more likely to be hospitalized than individuals without dementia. Little is known about key features (i.e., structural capabilities) in primary care practices where PLWD receive care. This study assessed the relationship between structural capabilities (i.e., care coordination, community integration, and reminder systems) and hospitalizations among PLWD. Methods: We conducted a secondary analysis of cross-sectional data from 5001 PLWD in 192 practices and used three datasets: nurse practitioner surveys, Medicare claims, and Minimum Data Set. Using generalized estimating equations, we evaluated the association between structural capabilities and hospitalizations. Results: PLWD who received care from practices with care coordination were less likely to have hospitalizations (OR = 0.62, p < .05). No statistically significant associations were observed between community integration and reminder systems and hospitalizations. Conclusion: Primary care practices need to tailor structural capabilities to address the needs of PLWD to reduce hospitalizations.

Primary Care Nurse Practitioner Burnout and ED Use and Hospitalizations Among Chronically Ill Medicare Beneficiaries.

Nurse practitioners (NPs) represent the fastest-growing workforce of primary care clinicians in the United States. Their numbers are projected to grow in the near future. The NP workforce can help the country meet the rising demand for care services due to the aging population and increasing chronic disease burden. Yet, increased burnout among these clinicians may affect their ability to deliver high-quality, safe care. We investigated how NP burnout in primary care practices affects patient outcomes, including emergency department (ED) use and hospitalizations, among older adults with chronic conditions. In 2018-2019, we collected survey data from 1244 primary care NPs from 6 geographically diverse states on their burnout and merged the survey data with data from Medicare claims on ED use and hospitalizations among 467 466 older adults with chronic conditions. 26.3% of NPs reported burnout. Using logistic regression models, we found that with a 1-unit increase in the standardized burnout score, the odds of an ED visit increased by 2.8% (OR = 1.028; P-value = .035); Ambulatory Care Sensitive Conditions (ACSC) ED visit by 3.2% (OR = 1.032; P-value = .019); hospitalization by 3.9% (OR = 1.039; P-value = .001); and ACSC hospitalization by 6.2% (OR = 1.062; P-value = .001). Our findings indicate that if chronically ill older adults receive care in primary care practices with higher NP burnout rates they are more likely to use EDs and hospitals. Policy and practice efforts, such as improving NP working conditions, should be undertaken to reduce NP burnout in primary care practices to potentially prevent acute care use.

Structural capabilities in primary care practices where nurse practitioners care for persons living with dementia.

BACKGROUND: Primary care structural capabilities (i.e., electronic health records, care coordination, community integration, and reminder systems) can address the multiple needs of persons living with dementia (PLWD). OBJECTIVES: This study describes structural capabilities in primary care practices where nurse practitioners (NPs) provide care to PLWD and compares the presence of structural capabilities in practices with a high and low volume of PLWD. METHODS: We conducted a secondary analysis of cross-sectional data from 293 NPs in 259 practices in California. Logistic regression models were used to determine the association between the volume of PLWD and the presence of structural capabilities. RESULTS: NPs reported that 96% of practices had electronic health records, 61% had community integration, 55% had reminder systems and 35% had care coordination capabilities. Practices with a high volume of PLWD were less likely to have community integration compared to practices with a low volume of PLWD. CONCLUSION: Many PLWD-serving practices do not have the essential infrastructure for providing optimal dementia care. Practice managers should focus on implementing the essential structural capabilities to address the complex needs of PLWD. IMPLICATIONS FOR PRACTICE: Clinicians and practice administrations can use the findings of this study to improve the delivery of care in practices that provide care to PLWD.

The Impact of Ambulatory Dementia Care Models on Hospitalization of Persons Living With Dementia: A Systematic Review.

This systematic review presents an overview of the existing dementia care models in various ambulatory care settings under three categories (i.e., home- and community-based care models, partnership between health systems and community-based resources, and consultation models) and their impact on hospitalization among Persons Living with Dementia (PLWD). PRISMA guidelines were applied, and our search resulted in a total of 13 studies focusing on 11 care models. Seven studies reported that utilization of dementia care models was associated with a modest reduction in hospitalization among community-residing PLWD. Only two studies reported statistically significant results. Dementia care models that were utilized in specialty ambulatory care settings such as memory care showed more promising results than traditional primary care. To develop a better understanding of how dementia care models can be improved, future studies should explore how confounders (e.g., stage of dementia) influence hospitalization.

The Association between Health Professional Shortage Area (HPSA) Status, Work Environment, and Nurse Practitioner Burnout and Job Dissatisfaction.

Clinicians in health professional shortage areas (HPSAs) often work in practices with fewer resources and higher workloads, challenging recruitment and retention efforts. Nurse practitioners (NPs) frequently care for underserved patients in HPSAs. As a result, HPSA NPs may be susceptible to poor workforce outcomes, including burnout and job dissatisfaction. Using multiple logistic regression, our study assessed the relationship between the work environment and the odds of burnout and job dissatisfaction, and whether HPSA status moderated the relationship between a good work environment and lower odds of these negative outcomes. Consistent with prior research, we found that better work environments significantly decreased the odds of burnout and job dissatisfaction. Working in an HPSA was not associated with NP burnout or job dissatisfaction, nor did HPSA moderate the relationship between the work environment and NP job outcomes. Thus, improving work environments holds promise for reducing negative NP workforce outcomes regardless of HPSA designation.

Primary care practice structural capabilities in health professional shortage areas.

OBJECTIVES: To evaluate structural capabilities in primary care practices employing nurse practitioners (NPs) and test whether they differ across health professional shortage areas (HPSAs) and non-HPSAs. STUDY DESIGN: Secondary analysis of cross-sectional survey data and health care workforce data from 2018-2019. METHODS: We computed bivariate analyses and multivariable adjusted regression models to evaluate differences in NP characteristics and practice characteristics and to determine the odds of having particular structural capabilities in HPSA practices compared with non-HPSA practice. RESULTS: The majority of NPs worked in HPSA practices (61%). We found statistically significant differences in NP educational degrees, practice certifications, and structural capabilities between HPSAs and non-HPSAs. Care coordination was 77% more likely to be delivered in HPSA practices compared with non-HPSA practices (odds ratio, 1.77; P < .05). CONCLUSIONS: Expanding care coordination may be beneficial for HPSA populations with high rates of morbidity and socioeconomic needs. Future research is needed to understand how the NP workforce may be optimized to meet the growing primary care demands in underserved areas.

The Critical Need for a Meaning-Centered Team-Level Intervention to Address Healthcare Provider Distress Now.

COVID-19 has unveiled and amplified the burnout, grief, and other forms of distress among healthcare providers (HCPs) that long preceded the pandemic. The suffering of the healthcare workforce cannot be simply and sufficiently addressed with a single psychotherapeutic intervention. Nevertheless, the National Academies of Sciences, Engineering, and Medicine Studies recommended prioritizing interventions that generate an increased sense of meaning in life and in work to reduce burnout and cultivate clinician wellbeing. Despite their guidance, there is a dearth of interventions for HCPs specifically targeting meaning and purpose as an avenue to reduce HCP distress. In a time when such an intervention has never been more essential, Meaning-Centered Pyschotherapy (MCP), a brief, evidence-based intervention designed for patients with advanced cancer may be key. This piece describes the principles underlying MCP and how it might be adapted and applied to ameliorate burnout among HCPs while providing a rationale to support future empirical studies in this area. Importantly, the systemic factors that contribute to the emotional and mental health burdens of HCPs are discussed, emphasizing the need for systems-level changes that are needed to leverage the potential outcomes of MCP for HCPs.

Three-Year Nursing PhD Model Recommendations from the RWJF Future of Nursing Scholars.

BACKGROUND: In response to the 2011 Future of Nursing report, the Robert Wood Johnson Foundation created the Future of Nursing Scholars (FNS) Program in partnership with select schools of nursing to increase the number of PhD-prepared nurses using a 3-year curriculum. METHOD: A group of scholars and FNS administrative leaders reflect on lessons learned for stakeholders planning to pursue a 3-year PhD model using personal experiences and extant literature. RESULTS: Several factors should be considered prior to engaging in a 3-year PhD timeline, including mentorship, data collection approaches, methodological choices, and the need to balance multiple personal and professional loyalties. Considerations, strategies, and recommendations are provided for schools of nursing, faculty, mentors, and students. CONCLUSION: The recommendations provided add to a growing body of knowledge that will create a foundation for understanding what factors constitute "success" for both PhD programs and students. [J Nurs Educ. 2022;61(1):19-28.].

Leveraging the Work Environment to Minimize the Negative Impact of Nurse Burnout on Patient Outcomes.

BACKGROUND: Burnout remains a persistent issue affecting nurses across the US health system. Limited evidence exists about the direct impact of nurse burnout on patient outcomes. This study explores the relationship between nurse burnout and mortality, failure to rescue, and length of stay, while also considering the effect of a good work environment. METHODS: Cross sectional data from nurses and hospitals were used in conjunction with patient claims data. Multivariate logistic regression was used to study the relationship between nurse burnout, patient outcomes, the work environment, and Magnet status. RESULTS: Higher odds of patient mortality, failure to rescue, and prolonged length of stay were found in hospitals that had, on average, higher nurse burnout scores. Good work environments were found to attenuate the relationship between nurse burnout and mortality, failure to rescue, and length of stay. Magnet status, another indicator of a good work environment, was found to attenuate the relationship between nurse burnout and mortality and failure to rescue. CONCLUSIONS: Improving the work environment remains a solution for hospitals looking to concurrently improve nurse burnout and patient outcomes. Administrators may look to the Magnet recognition program as a blueprint to better support nurses in providing safe, high quality care.