Does the Regulatory Environment Affect Nurse Practitioners' Patterns of Practice or Quality of Care in Health Centers?

OBJECTIVE: To examine the impact of state-granted nurse practitioner (NP) independence on patient-level quality, service utilization, and referrals. DATA SOURCES/STUDY SETTING: The National Ambulatory Medical Care Survey's community health center (HC) subsample (2006-2011). Primary analyses included approximately 6,500 patient visits to 350 NPs in 220 HCs. STUDY DESIGN: Propensity score matching and multivariate regression analysis were used to estimate the impact of state-granted NP independence on each outcome, separately. Estimates were adjusted for sampling weights and NAMCS's complex design. DATA COLLECTION/EXTRACTION METHODS: Every "NP-patient visit unit" was isolated using practitioner and patient visit codes and, using geographic identifiers, assigned to its state-year and that state-year's level of NP independence based on scope of practice policies. Nine outcomes were specified using ICD-9 codes, standardized drug classification codes, and NAMCS survey items. PRINCIPAL FINDINGS: After matching, no statistically significant differences in quality were detected by states' independence status, although NP visits in states with prescriptive independence received more educational services (aIRR 1.66; 95 percent CI 1.09-2.53; p = .02) and medications (aIRR 1.26; 95 percent CI 1.04-1.53; p = .02), and NP visits in states with practice independence had a higher odds of receiving physician referrals (AOR 1.88; 95 percent CI 1.10-3.22; p = .02) than those in restricted states. CONCLUSIONS: Findings do not support a quality-scope of practice relationship.

Dual Eligibles' Experience of Care with North Carolina's Patient-Centered Medical Home.

Although individuals enrolled in both Medicare and Medicaid (dual eligibles) are among those with the nation's greatest need, at $300 billion per year, their care is also expensive and beset by quality problems. Previous research found problems associated with inadequate coordination of benefits and services; however, these studies have largely used quantitative approaches and focused on providers-few studies have explored the perspective of dual eligible patients. In an effort to improve care and reduce costs, North Carolina (NC) developed a Patient-Centered Medical Home (PCMH) model centered on a continuous relationship with a primary care provider who is responsible for coordination of services and addressing patients' health care needs by providing direct services or arranging care with other qualified professionals. This article presents the history of the NC PCMH model and describes results of an in-depth qualitative investigation of dual eligible patients' experience of care with this model. Experience of care was captured through 11 focus groups with 61 dual eligible patients. Focus groups were audio recorded and analyzed using NVivo 9 software, which supported the categorization of data into themes based on frequency and intensity of discussions. Findings indicate that dual eligible patients were generally satisfied by the care received through the NC PCMH program. However, many patients reported continuity of care issues, problems accessing necessary prescription drugs, and difficulties navigating the health care delivery system. Findings also revealed that conflicting state and federal Medicaid drug co-pay policies confused and limited access for some patients.

Hearing aids for nursing home residents: current policy and future needs.

Hearing aids are crucial for people with hearing loss, especially dementia patients in nursing homes. However, the actual use of hearing aids in this population is very low. A major barrier to use is the cost. This paper examines the issue in terms of current financial coverage available through federal and state systems as well as private insurance. We discuss the applicability of the Americans with Disabilities Act (ADA) and other federal laws to this problem. There is a need for future policy development to improve both the quality of hearing aids and the financial mechanisms that will allow nursing home residents to use them. Plans to move the policy agenda forward are suggested.

Policy initiatives to promote healthy aging.

An overwhelming array of policies and programs can be used to help older people (and future older people) maintain healthy lifestyles. How can clinicians help ensure that their patients take advantage of these opportunities? How can these broad-scope policies, educational and information initiatives, and direct service programs be turned into tools to help older people maximize health and independence? First, physicians do not need to do it all themselves. They need to know where to send their patients. For example, case managers in local aging service organizations and social workers, nurses, and discharge planners in hospitals can help connect elderly patients to appropriate benefits and services. Physicians play a critical role in creating a bridge between patients and the array of programs and information that can help them change their individual patterns of behavior. A serious lack of integration exists between what is known about healthy behaviors and lifestyles and what is really happening and available to older people today. From the earlier articles in this issue we know that much can be done to prevent many types of age-related disease and disability. This article provides examples of mechanisms that can be used to broadly disseminate knowledge about effective behavior and treatment changes and create mechanisms to turn this knowledge into real and widespread client-level, practice-level, health system, and community-wide interventions. Second, physicians need to understand that they are not merely subject to these policies and initiatives. They can help formulate and shape them. This political involvement includes active participation in policy initiatives of professional associations, involvement in research and demonstration activities, keeping informed about policy proposals at the federal and state levels, and helping advance ideas for improving health behaviors by speaking up and working toward change. These changes go beyond health initiatives to involve improving housing, nutrition, transportation, and other arenas that play a role in the health of communities and cities. According to the IOM, the most successful interventions are aimed at families, neighborhoods and communities. Interventions are also most likely to be successful when legislative, media, and marketing efforts support them [50]. These broader policies may actually have the most potential impact in terms of developing sustainable lifestyle changes that reach all Americans, especially those with the greatest health needs. Within the aging population, those with greatest health needs include members of minority groups, recent immigrants, and the old-old. These groups are often overlooked when designing and implementing health promotion programs. It is important, however, to remember, for patients and for ourselves, you are never too old to benefit from prevention.