The John A. Hartford Foundation For Geriatric Nursing / Best Practices /Nursing Counts - Winter 2000

Winter 1999 Volume 2 Number 4

Home Health Care and Ambulatory Care

This issue of Nursing Counts focuses on nurses who work in home health care and ambulatory care. Although not specifically related to these practice sites, we could not help but comment on California's recent decision to adopt regulations establishing minimum, specific, and numerical licensed nurse-to-patient ratios in hospitals (AB394). The Department of Health will establish the ratios. See the California Nurses Association's press release. Although HCFA has mandatory RN staffing levels for nursing homes and some states have set RN staffing levels for special care units such as ICUs, mandating RN staffing levels in hospitals is very controversial. It is a divisive issue within nursing that has tended to split staff nurses from nurse managers.

Arguments pro and con fall into the two general areas of government regulation and research-base.

First is which areas of hospital practice should be regulated to protect the public's health and which areas are best left to either voluntary accreditation or to each hospital to manage on its own. Some people think regulation protects the public, while others believe a market free of regulation will respond to consumer demands and permit institutional flexibility.

Second is the question of whether there is enough research-based information on which to establish staffing levels. Neither researchers nor policy makers can agree on how much research is needed to make such informed decisions. There is research that supports an inverse relationship between RN staffing levels and patient outcomes, including mortality and adverse patient events. However, there is no literature on what minimum safe staffing levels are.

In health care, California has served as a bellwether for what we can expect to happen in the rest of the country. California hospitals dramatically decreased length of hospital stay and the state was an early leader in the managed care movement. California is the first state to mandate that its Department of Health set mandatory RN staffing levels in general medical-surgical units in hospitals. The nation will be carefully watching the implementation of the new law, which we hope will encourage other states to think about the best approach to ensure high quality nursing care in hospitals.

Christine Kovner, Editor
Charlene Harrington, Associate Editor

IN THE COMMUNITY
	2.4 million persons received home health care in 1996(NCHS, 1996).
	72% of home health care recipients were 65 and older in 1996 (NCHS, 1996).
	Home health recipients tended to be 65 and older, female, white, and married or widowed in 1996 (NCHS, 1996).
	Over 6% of newly licensed registered nurses worked in community-based care in April 1999 (National Council State Boards of Nursing, 1999).


	Over 19% of newly licensed, licensed practical nurses worked in community-based care in April 1999 (National Council State Boards of Nursing, 1999).
	Over 14% of nurse practitioners worked in community-based care in 1996 (HRSA, Division of Nursing, 1996).
	75% of Americans had at least one ambulatory care visit with either a physician or nonphysician provider in 1996 (AHCPR, 1999).

Sources: The complete list of citations can be obtained from Tammy Fisher at tjf207@nyu.edu

Fast Facts

Counting Nurses

Primary Care Nurses

Research Briefs

Winter 2000:

Hospitals

Counting Nurses

How many people are there in the total U.S. health workforce? In a previous column, I wrote about two difficulties when counting nurses. First, some data sources (e.g. U.S. Department of Labor (DOL) Occupational Employment Surveys) count positions NOT people. An individual working part-time, which is often the case in home care, would be counted the same as a person working full-time. Similarly, a person holding two positions is counted twice. Second, for those data sources that count people, some count individuals (e.g., HRSA's National Sample Survey of Registered Nurses), while others count full-time equivalents employees (e.g., American Hospital Association). There is a third difficulty and it is definitional.

Recently I was on a panel at a meeting, where the moderator was from the DOL. He claimed that there were about nine million health care workers. My heart pounded a bit, as I knew that my second slide showed that there were about 13,477,000 health care workers (9.7% of the civilian work force), 4.5 million more workers than the DOL member reported. I had confidence in my number, as it was from the Bureau of the Census Current Population Survey (CPS) from March 1999.

I showed the slide as planned and pointed out that the 4.5 million probably was not a rounding error. In the discussion that followed, we decided that the likely explanation was how the data collectors defined a health worker. Many people count anyone working in a health facility as a health care worker. In addition to those people working in health organizations, there are health professionals working in other settings, such as schools. The CPS definition includes both of these groups. Thus, a security guard working at a hospital and a nurse working for an insurance company would be counted as part of the health work force.

Christine Kovner, Editor

U.S. HEALTH WORKFORCE

PERSONS WHO VISIT PHYSICIANS AND NONPHYSICIAN PROVIDERS

Figure 1 shows the percentage of persons by age groups who visit physician and nonphysician providers. As illustrated, those persons 65 and older have more health care visits from nonphysician providers than do people of any other age group.

Age in Years

(click image for larger picture)

Note: Restricted to civilian noninstitutionalized population. Nonphysician providers include nurses and nurse practitioners, chiropractors, podiatrists, optometrists, physical and occupational therapists, and mental health workers. Reflects age on 12/31/96 except that age at last interview was used for persons who were not in the survey on 12/31/96. Total for ages 6-17 does not add to 100.0 because of rounding.

VISITS TO NURSES AND NURSE PRACTIONERS

Figure 2 illustrate that persons who are65 and older use nurses and nurse practitioners during ambulatory care visits more frequently than persons 65 and under.

65 years of age and over

Under 65 years of age

VISITS TO NONPHYSICIAN PROVIDERS

Figure 3 shows that 39.5% of visits to nonphysican providers are to nurses or nurse practioners. Note that the remaining 60.5% of visits are to a wide variety of health care providers.

Note: Nonphysican providers include chiropractors, podiatrists, optometrists, physical and occupational therapists, and mental health workers

Primary Care Nurses and Homecare

Advanced Practice Nurses have been practicing in homecare for many years. Most of them are Clinical Nurse Specialists (CNSs) that provide specialty nursing care. Nurse Practitioners (NPs) have not been attracted to homecare because their practice role has not been able to be fully used in homecare. Recently, a number of events have occurred to make the place of the Nurse Practitioner in homecare a reality.

The advent of managed health care has resulted in rapid patient discharges from hospitals, placing sicker, medically unstable people at home. These are often elderly and frail individuals, whose unstable condition often results in readmission to the hospital, adding substantial costs to the insurers. Nurse Practitioners who care for persons at home report that in addition to reduced hospital readmissions, medication costs and costs related to other services (i.e., ambulance transportation) are decreased by their interventions. Changing Medicare reimbursement rules have also increased the use of NPs. Due to the Balance Budget Act of 1997, which enables reimbursement of NPs and CNSs in all practice settings, homecare agencies have authorization to bill for NP and CNS services.

Barbara Sadowsky is a NP who works in homecare. She is an Adult/Geriatric Nurse Practitioner who established and maintained an independent nurse practitioner program, which delivered primary health care to ambulatory and homebound people from 1985 until 1993. She was forced to disband her practice due to inadequate reimbursement, despite excellent results for her patients. With recent changes in Medicare reimbursement, her practice today would probably be financially viable.

Currently she works with the Visiting Nurse Service of NY (VNSNY, Queens branch). The VNS is exploring several avenues toward utilization of nurse practitioners. Barbara's long experience in homecare will help them to develop a practice model for other Advanced Practice Nurses. In addition, other VNSs have started NP House Call Programs and private medical practices are beginning to employ NPs to do primary homecare.

Joan Mason, Coordinator: Advance Practice Home Health Nursing
Division of Nursing, New York University



	COST OF LONG-TERM CARE Cost-effective use of various long-term care options is dependent on targeting services to persons who could be most efficiently cared for in each of different care settings in a resource scarce environment. This study identified subgroups with a high potential for reduced cost of care in different care settings by employing some measures of physical impairment. The findings indicated that for elderly persons with high physical impairment, the cost of care was higher in home care than in a nursing home care setting. Taewha Lee Lee, T. (1997). The cost of long-term care alternatives for the elderly. Unpublished doctoral dissertation, New York University, New York.		HOME HEALTH CARE UTILIZATION Torrez, Estes, and Linkens (1998) identified the predictors of the amount and type of home health care services received in California and Pennsylvania by persons 65 and older. Using regression analysis models, they found that the Activities of Daily Living (ADLs) and the agency characteristics, tax status and payer source, were significantly related to the number of types of services received. Similarly, these were significant predictors of the number of visits certified, along with client characteristics such as a client's age and race. However, when examining the client and agency-level data separately, the number of ADLs was the most significant predictor of service utilization. Interestingly, when assessing the overall access to home health care services among those persons 65 an older, Torrez et al. concluded that access did not increase following changes in Medicare home health care eligibility in 1989. Tammy Fisher Torrez, D.J., Estes, C., & Linkens, K. (1998). The impact of a decade of policy on home health care utilization. Home Health Care Services Quarterly, 16(4), 35-56.

�2000. Hartford Institute, New York University Division of Nursing.