Improving Access to High-Quality Care throughGraduate Nurse Education

Haley MorinSUMR 2017 | Mentor: Dr. Matthew McHugh

Haley Morin Dr. Matthew McHugh,PhD, JD, MPH, RN, CRNP, FAAN

The Independence Chair for Nursing Education

Professor of Nursing

Associate Director, Center for Health Outcomes and Policy Research

Faculty Director, Nursing and Health Care Management Coordinated Dual Degree Program

Leonard Davis Institute SUMR Scholar 2017

Rising Senior, University of Pennsylvania

Nursing and Healthcare Management Dual Degree Program

Problem

ROADMAP

Opportunity Legislation Research Future

THE PROBLEM:Shortages and Maldistribution of Healthcare Providers

1

““By 2025, demand for physicians will exceed

supply by a range of 46,000 to 90,000.”

-AAMC, 2015

1 - THE PROBLEM

CARE SHORTAGE

⊡ Decades of support to incentivize physicians to enter primary care

⊡ Number physicians entering primary care less than number retiring

⊡ Less than 2000 medical students a year enter primary care residencies

⊡ Number of physicians entering primary care workforce is too small to meet demand

http://www.nationalacademies.org/hmd/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Infographic.aspx

THE OPPORTUNITY:Advance Practice Registered Nurses

2

HIGH QUALITY⊡ Outcomes of patients cared for by

NPs are comparable to and in some respects better than the care delivered by physicians □ Horrocks, et al., 2002; Kuo, Chen,

Baillargeon, Raji, & Goodwin, 2015; Mundinger et al., 2000; Newhouse, et al., 2011; Spitzer et al., 1974

⊡ Chronic illness management by NPs is equally as effective as physician-managed care □ Horrocks, et al., 2002; Mundinger, et al.,

2000; Stanik-Hutt, et al., 2013

⊡ Preventative cancer screenings are increased with NP-provided primary care□ Mandelblatt et al., 1993

2 - THE OPPORTUNITY

HIGH SATISFACTION⊡ Patients are highly satisfied with

care provided by NPs □ Horrocks, et al., 2002; Newhouse, et al.,

2011

⊡ Millions of fully-insured patients with a choice of providers elect care by NPs □ Dill, Pankow, Erikson, Shipman, 2013;

Druss et al., 2003

COSTS⊡ Primary care NPs’ outcomes for

preventing hospitalizations for patients with chronic illnesses are equivalent to physicians □ Kuo et al., 2015

⊡ NPs in acute care settings decrease length of stay and hospitalization costs and reduce hospital readmissions after discharge to home□ Collins et al., 2014; Edkins, Cairns, &

Hultman, 2014; Kapu, Kleinpell, & Pilon, 2014; Newhouse, et al., 2011

□ McCauley, Bixby, & Naylor, 2006; Naylor et al., 2004

2 - THE OPPORTUNITY

ACCESS⊡ NPs are more likely than

physicians to provide care to Medicaid beneficiaries and underserved populations□ Buerhaus, DesRoches, Dittus, &

Donelan, 2015

⊡ In states with full NP practice authority, appointment availability for Medicaid patients is better and visit costs are lower in primary care practices with NPs□ Richards & Polsky, 2015

2 - THE OPPORTUNITY

IOM REPORT 2010

The totality of evidence in favor of expanding the supply of NPs led the Institute of Medicine to recommend the elimination of regulations and payment barriers to the full participation of NPs in the nation’s healthcare

2 - THE OPPORTUNITY

ISSUES AND BARRIERS

⊡ Demand for NPs is currently outstripping supply□ Adversely affecting access to healthcare

⊡ A major barrier to nursing schools producing more NPs is difficulty recruiting clinical preceptors□ Loss of productivity□ Space limitations□ Competition

⊡ Increasing difficulty of recruiting clinical preceptors⊡ Public funding for NP education minimal

□ How much money goes to GNE?□ Graduate Medical Education is roughly $9 billion a year

THE LEGISLATION:Graduate Nursing Education Demonstration

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3 - THE LEGISLATION

GNE DEMONSTRATION

⊡ Affordable Care Act demonstration for $200 million⊡ Primary intervention

□ Provider payment incentive through provider organizations□ Financed by Medicare payments same way as residency

programs□ Pays for clinical training costs of NPs

⊡ Must have at least 50% of the demonstration supporting clinical training in primary care

⊡ Five hospital sites selected through competitive application process□ 4 year demonstration program (extended one year)□ Schools attached to hospitals/health systems

3 - THE LEGISLATION

DEMONSTRATION SITES

⊡ Hospital of University of Pennsylvania, Philadelphia PA

⊡ Memorial Hermann-Texas Medical Center, Houston TX

⊡ Honor Health for the State of Arizona, Scottsdale, AZ

⊡ Rush University Medical Center, Chicago, IL

⊡ Duke University Health System Durham, NC

THE RESEARCH:Evaluation of GNE Demonstration

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OBJECTIVEExploit opportunity created by $200 million GNE demonstration to determine whether Medicare payments to hospitals and community organizations is associated with:

⊡ Substantial overall increases in NP enrollments and graduations⊡ Substantial increases in student enrollments and graduations in primary care

4 - THE RESEARCH

4 - THE RESEARCH

GNE non-GNE

4 - THE RESEARCH

GNE

non-GNE

DATA ANALYSIS

⊡ R and STATA□ Merge, merge, merge□ MatchMutli package in R

⊡ Multivariate match□ Want close balance in characteristics between non-GNE sites and GNE sites□ Balance assessed using standardized differences in means, histograms,

jitter plots

4 - THE RESEARCH

MATCHING VARIABLES

⊡ Preceptor market competition□ Hospital discharge volume □ Market share using DOJ definitions of market concentration□ Acute care beds, primary care physicians, outpatient visits, FQHC

⊡ Nursing school market competition□ Nursing school graduate volume for NPs and RNs□ Related market indicators such as RN and NP per 100,000 residents

⊡ Demographic composition□ Population, rural/urban, racial demographics, poverty, health profession

shortage⊡ Outcomes

□ Enrollments and graduations in baseline□ Nurse practitioners, nurse midwives, clinical nurse specialists, nurse

anesthetists

4 - THE RESEARCH

THE FUTURE:Policy Implication and the Future of Healthcare

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5 - THE FUTURE

POLICY IMPLICATIONS

⊡ Evaluation can help make the case for continued GNE funding⊡ Production of more NPs?⊡ Improved cost, quality, and access in primary care and beyond

LESSONS LEARNED

⊡ You can teach yourself anything on YouTube⊡ Working with data can be tedious⊡ Timelines are sometimes out of your control

THANKS!

Any questions?

Thank you to Dr. McHugh, Joanne Levy, Safa Browne, Hoag Levins, Kathryn Lee, and Joshua Dahlerbruch

Slide theme from slidescarnival.com

REFERENCESBuerhaus, P. I., DesRoches, C. M., Dittus, R., & Donelan, K. (2015). Practice characteristics of primary care nurse practitioners and physicians. Nursing Outlook, 63(2), 144-153.

Collins, N., Miller, R., Kapu, A., Martin, R., Morton, M., Forrester, M., . . . Wilkinson, L. (2014). Outcomes of adding acute care nurse practitioners to a Level I trauma service with the goal of decreased length of stay and improved physician and nursing satisfaction. The Journal of Trauma and Acute Care Surgery, 76(2), 353-357.

Dill, M. J., Pankow, S., Erikson, C., & Shipman, S. (2013). Survey shows consumers open to a greater role for physician assistants and nurse practitioners. Health Affairs, 32(6), 1135-1142.

Edkins, R. E., Cairns, B. A., & Hultman, C. S. (2014). A systematic review of advance practice providers in acute care: options for a new model in a burn intensive care unit. Annals of Plastic Surgery, 72(3), 285-288.

Horrocks, S., Anderson, E., & Salisbury, C. (2002). Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors. BMJ, 324(7341), 819-823.

Kapu, A. N., Kleinpell, R., & Pilon, B. (2014). Quality and financial impact of adding nurse practitioners to inpatient care teams. The Journal of Nursing Administration, 44(2), 87-96.

Kuo, Y. F., Chen, N. W., Baillargeon, J., Raji, M. A., & Goodwin, J. S. (2015). Potentially preventable hospitalizations in Medicare patients with diabetes: A comparison of primary care provided by nurse practitioners versus physicians. Medical Care, 53(9), 776-783.

Mandelblatt, J., Traxler, M., Lakin, P., Thomas, L., Chauhan, P., Matseoane, S., & Kanetsky, P. (1993). A nurse practitioner intervention to increase breast and cervical cancer screening for poor, elderly black women. The Harlem Study Team. Journal of General Internal Medicine, 8(4), 173-178.

McCauley, K. M., Bixby, M. B., & Naylor, M. D. (2006). Advanced practice nurse strategies to improve outcomes and reduce cost in elders with heart failure. Disease Management, 9(5), 302–310.

Mundinger, M. O., Kane, R. L., Lenz, E. R., Totten, A. M., Tsai, W. Y., Cleary, P. D., . . . Shelanski, M. L. (2000). Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. JAMA, 283(1), 59-68.

Naylor, M. D., Brooten, D. A., Campbell, R. A., Maislin, G., McCauley, K. M., & Schwartz, J. S. (2004). Transistional care of older adults hospitalized with heart failure: a randomized, controlled trial. Journal of American Geratrics Society, 5(2), 675-684.

Newhouse, R. P., Stanik-Hutt, J., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., . . . Heindel, L. (2011). Advanced practice nurse outcomes 1990-2008: A systematic review. Nursing, 29(5), 1.

Richards, M. R., & Polsky, D. (2015). Influence of provider mix and regulation on primary care services supplied to U.S. patients. Health Economics, Policy, and Law, 11(12), 193-213.

Stanik-Hutt, J., Newhouse, R. P., White, K. M., Johantgen, M., Bass, E. B., Zangaro, G., . . . Weiner, J. P. (2013). The quality and effectiveness of care provided by nurse practitioners. The Journal for Nurse Practitioners, 9(8), 492-500.