Assessing health literacy in safety net primary care practices.

Health literacy is now recognized as a crucial element of patient safety. Measuring health literacy in busy primary care practices can be challenging. This article presents findings from a study in which a relatively recent tool, the Newest Vital Sign (NVS) was used in seven safety net primary care practices, five of which were nurse managed health centers. The NVS is a promising tool that could be used extensively in most primary care practices. Providers and staff felt the use of the NVS would be beneficial in identifying low health literacy patients. This study supported previous research on low health literacy as well as the predictors of health literacy. The study also confirmed the NVS as a tool that is efficient to administer while maintaining work flow.

Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.

PURPOSE: This study, conducted in five safety-net practices, including two nurse-managed health centers (NMHCs) and three federally qualified health centers (FQHCs), examined the impact of implementing a commercial electronic health records (EHRs) system on medication safety. DATA SOURCE: A mixed methods approach with two sources of data were used: (a) a query of prescription records captured by the EHR retrieving co-prescribed medications with identified drug-drug interaction (DDI) risks, and (b) semistructured interviews with clinicians and leadership about the usability and benefits of EHR-embedded clinical decision support in the form of DDI alerts. CONCLUSIONS: We found an exceptionally low rate of DDI pairs in all five practices. Only 130 "true" DDI pairs were confirmed representing 149,087 visits and 62 providers. Among the 130, the largest categories were related to antihypertensive medications, which are in fact often prescribed together. There were no significant differences between physicians and nurse practitioners on the rate of DDI pairs nor between NMHCs and FQHCs. IMPLICATIONS FOR PRACTICE: Implementation of an EHR in these five safety-net settings had a positive impact on medication safety. The issue of missing end dates is noteworthy in terms of DDIs and unnecessary alerts that could lead to alert fatigue.

Use of a comprehensive patient safety tool in primary care practices.

PURPOSE: To present a tool that can be used to evaluate patient safety in both nurse-led and physician-led practices. DATA SOURCE: This article describes our experience with the Physician Practice Patient Safety Assessment (PPPSA) tool in six safety net practices-three of which were primary care nurse-managed health centers and three were physician-led federally qualified health centers. The information provided is from the tool itself and how it might be used in clinical settings, especially primary care. CONCLUSIONS: The PPPSA is a tool to measure the extent to which patient safety practices are rigorously and systematically implemented throughout a health center. The tool's methodology requires discussion and consensus, incorporating a team approach with multiple perspectives within a center. It is designed to promote changes in practices that would improve patient safety. IMPLICATIONS FOR PRACTICE: The tool has enormous relevance for primary care settings, especially those preparing themselves for patient-centered medical home status and meaningful use. But most important, it has relevance as we create healthcare environments that promote patient safety and a practice culture that is truly patient centered.

Factors associated with smoking among operating engineers.

Although disparities in smoking prevalence between white collar workers and blue collar workers have been documented, reasons for these disparities have not been well studied. The objective of this study was to determine variables associated with smoking among Operating Engineers, using the Health Promotion Model as a guide. With cross-sectional data from a convenience sample of 498 Operating Engineers, logistic regression was used to determine personal and health behaviors associated with smoking. Approximately 29% of Operating Engineers currently smoked cigarettes. Multivariate analyses showed that younger age, unmarried, problem drinking, physical inactivity, and a lower body mass index were associated with smoking. Operating Engineers were at high risk of smoking, and smokers were more likely to engage in other risky health behaviors, which supports bundled health behavior interventions.

Factors associated with sleep quality among operating engineers.

Blue collar workers generally report high job stress and are exposed to loud noises at work and engage in many of risky health behavioral factors, all of which have been associated with poor sleep quality. However, sleep quality of blue collar workers has not been studied extensively, and no studies have focused Operating Engineers (heavy equipment operators) among whom daytime fatigue would place them at high risk for accidents. Therefore, the purpose of this study was to determine variables associated with sleep quality among Operating Engineers. This was a cross-sectional survey design with a dependent variable of sleep quality and independent variables of personal and related health behavioral factors. A convenience sample of 498 Operating Engineers was recruited from approximately 16,000 Operating Engineers from entire State of Michigan in 2008. Linear regression was used to determine personal and related health behavior factors associated with sleep quality. Multivariate analyses showed that personal factors related to poor sleep quality were younger age, female sex, higher pain, more medical comorbidities and depressive symptoms and behavioral factors related to poor sleep quality were nicotine dependence. While sleep scores were similar to population norms, approximately 34 % (n = 143) showed interest in health services for sleep problems. While many personal factors are not changeable, interventions to improve sleep hygiene as well as interventions to treat pain, depression and smoking may improve sleep quality resulting in less absenteeism, fatal work accidents, use of sick leave, work disability, medical comorbidities, as well as subsequent mortality.

Factors associated with health-related quality of life among operating engineers.

BACKGROUND: Because health-related quality of life among blue-collar workers has not been well studied, the purpose of this study was to determine factors associated with health-related quality of life among Operating Engineers. METHODS: With cross-sectional data from a convenience sample of 498 Operating Engineers, personal and health behavioral factors associated with health-related quality of life were examined. RESULTS: Multivariate linear regression analysis revealed that personal factors (older age, being married, more medical comorbidities, and depression) and behavioral factors (smoking, low fruit and vegetable intake, low physical activity, high body mass index, and low sleep quality) were associated with poor health-related quality of life. CONCLUSIONS: Operating Engineers are at risk for poor health-related quality of life. Underlying medical comorbidities and depression should be well managed. Worksite wellness programs addressing poor health behaviors may be beneficial.

Comparison of nurse managed health centers with federally qualified health centers as safety net providers.

Nurse Managed Health Centers (NMHCs) provide a critical safety net function in their communities, yet they often remain invisible and challenged in terms of financial sustainability. This paper presents a comparison of demographics and financial status of NMHCs and Federally Qualified Health Centers (FQHCs). The comparison is based on four years of annual NMHC national survey data that includes 42 NMHCs overall and the 2008 FQHC data in the Uniform Data System. Findings indicate that NMHCs and FQHCs serve very similar diverse populations yet funding and revenue differences were significant. NMHCs tend to rely more on grants and donations from the private sector as well as contracts while FQHCs have access to considerable federal support that is cost based when serving the underserved. In addition, NMHCs are challenged by the array of state, federal and third party insurers' regulations that often disadvantage nurse practitioners as primary care providers.

A partnership model for implementing electronic health records in resource-limited primary care settings: experiences from two nurse-managed health centers.

OBJECTIVE: To present a partnership-based and community-oriented approach designed to ease provider anxiety and facilitate the implementation of electronic health records (EHR) in resource-limited primary care settings. MATERIALS AND METHODS: The approach, referred to as partnership model, was developed and iteratively refined through the research team's previous work on implementing health information technology (HIT) in over 30 safety net practices. This paper uses two case studies to illustrate how the model was applied to help two nurse-managed health centers (NMHC), a particularly vulnerable primary care setting, implement EHR and get prepared to meet the meaningful use criteria. RESULTS: The strong focus of the model on continuous quality improvement led to eventual implementation success at both sites, despite difficulties encountered during the initial stages of the project. DISCUSSION: There has been a lack of research, particularly in resource-limited primary care settings, on strategies for abating provider anxiety and preparing them to manage complex changes associated with EHR uptake. The partnership model described in this paper may provide useful insights into the work shepherded by HIT regional extension centers dedicated to supporting resource-limited communities disproportionally affected by EHR adoption barriers. CONCLUSION: NMHC, similar to other primary care settings, are often poorly resourced, understaffed, and lack the necessary expertise to deploy EHR and integrate its use into their day-to-day practice. This study demonstrates that implementation of EHR, a prerequisite to meaningful use, can be successfully achieved in this setting, and partnership efforts extending far beyond the initial software deployment stage may be the key.

Quality of care in nurse-managed health centers.

PURPOSE: The purposes of this article are to: (a) describe the first, national, collection of quality measures for nurse-managed health centers (NMHCs); (b) present the quality findings; (c) compare findings with national ambulatory care benchmarks; and (d) discuss the feasibility of national quality data collection, including NMHCs' experiences with data submission and the utilization of findings. METHODS: Quality outcomes appropriate for aggregated assessment of NMHC quality were proposed by a committee of the National Institute for Nursing Centers. Quality measures related to these outcomes were developed for breast cancer screening, cervical cancer screening, diabetes care, hypertension management, and smoking cessation based on protocols of the Health care Effectiveness Data and Information Set. Nine NMHCs were recruited to participate in retrospective data collection, manually from record audits or electronically from the submission of data files. RESULTS: Overall, quality measure findings compared favorably with national benchmarks, with particularly high quality demonstrated for chronic disease care management. CONCLUSIONS: Good to very good quality of care was documented across NMHCs, and NMHCs compared favorably with national benchmarks. Data were useful to NMHCs in identifying quality strengths and areas for improvement. National data collection proved to be feasible.

Analysis & commentary. Unleashing nurse practitioners' potential to deliver primary care and lead teams.

Highly skilled primary care is a hallmark of high-performing health care systems. We examine nurse practitioners' role in delivering primary care and the effects of current restrictions on their ability to practice. By resolving differences between states' individual scope-of-practice regulations, we can fully benefit from the skills of advanced-practice nurses in all fifty states. We recommend substantive changes in the way health care professionals in all disciplines are trained, and in their roles, so that patients can receive appropriate and cost-effective care from skilled and fully functional health care teams.

Toward a national nurse-managed health center data set: findings and lessons learned over 3 years.

Although primary care nurse-managed health centers (NMHCs) have gained increasing recognition, there are limited standardized clinical and financial data on these centers. The purpose of this paper is to present the process, benefits, and challenges in collecting standardized national data based on a consensus process from NMHCs over 3 consecutive years. The Institute for Nursing Centers (INC) NMHC Survey focuses on demographic, clinical, and financial data. A detailed codebook accompanied the INC NMHC Survey. A total of 42 NMHCs responded in at least 1 of the 3 years. Despite the challenges in collecting some of the data, especially for the first survey year, data quality improved remarkably when the INC NMHC Survey was repeated. Financial data seemed to be more easily reported than demographic or clinical data. NMHCs increase access to care, often for vulnerable populations, yet to date there are limited standardized clinical and financial data on these centers. The INC NHMC Survey and data described in this paper begins to address that gap.

Quality and safety education for advanced nursing practice.

The Quality and Safety Education for Nurses (QSEN) project is a national initiative to transform nursing education to integrate quality and safety competencies. This article describes a two-year process to generate educational objectives related to quality and safety competency development in graduate programs that prepare advanced practice nurses in clinical roles. Knowledge, skills, and attitudes for each of 6 competencies are proposed to stimulate development of teaching strategies in programs preparing the next generation of advanced practice nurses.

Quality and safety in graduate nursing education: Cross-mapping QSEN graduate competencies with NONPF's NP core and practice doctorate competencies.

To ensure that nurse practitioners are prepared to deliver safe, high-quality health care, the National Organization of Nurse Practitioner Faculties (NONPF) publishes documents that outline the expected competencies for nurse practitioner (NP) practice (Domains and Core Competencies of Nurse Practitioner Practice and Practice Doctorate Nurse Practitioner Entry-Level Competencies). Having participated in the development of the Quality and Safety Education for Nurses (QSEN) competencies for graduate education, NONPF convened a task force to compare NONPF competencies with QSEN competencies for graduate education. This paper reports the first step of that cross-mapping process, comparing NONPF competencies with the QSEN knowledge objectives. Overall findings indicate close congruence across the 2 sets of competencies; however there are areas in which gaps are noted or for which clarification is required.

CPT coding patterns at nurse-managed health centers: data from a national survey.

Nurse-managed health centers (NMHCs) play an important role in delivering health care services to a wide range of communities and often serve as our nation's safety net providers. Unfortunately, NMHCs struggle to remain in business for a variety of reasons, including underdeveloped business practices. Until now, NMHCs had only data from the Centers for Medicare and Medicaid Services and the Medical Group Management Assocation for comparison with coding patterns in individual centers. This article is the first published report of national data for NMHCs that is available for comparison. Providers need to possess financial acumen to remain open for business. Assessment of CPT coding patterns is a key strategy to support long-term sustainability.

The influence of developmental life stage on quality of life in survivors of prostate cancer and their partners.

INTRODUCTION: Although prostate cancer is prevalent, little information is available on how it affects couples' quality of life (QOL) according to their age cohort. The purpose of this study was to examine how quality of life, self-efficacy and appraisal of the illness experience vary among men with prostate cancer and their partners according to age cohort: middle age (50-64); young-old (65-74); and old-old (75-84). Using an Adult Developmental and Family Stress framework, this study focuses on how normative (developmental stage) and non-normative stressors (prostate cancer) may affect a couple's ability to adapt. METHODS: A descriptive, comparative design was used to examine age-related differences in quality of life and selected psychosocial variables in 69 men with prostate cancer and their spouses. Cross-sectional data were obtained using standardized instruments with adequate reliability and validity. ANCOVA and MANCOVA were used to determine differences among age groups. RESULTS: Findings indicated that patients who were ages 65-74 had better QOL and higher self-efficacy than patients ages 50-64 and less negative appraisal of illness than the other two groups. Spouses ages 50-64 reported the most distress related to sexual changes in their husbands. Spouses in both the middle age and old-old group had more bother related to hormone therapy than the young-old spouses. IMPLICATIONS FOR CANCER SURVIVORS: Findings suggest that interventions should be tailored to dyads' developmental life stage. Younger and older prostate cancer survivors and their partners may benefit from tailored interventions designed to improve their quality of life and confidence in managing their treatment outcomes during the survivorship period.

Personal influencing factors associated with pap smear testing and cervical cancer.

Pap smear is a screening test that detects abnormal cells before they advance to cancer. Unfortunately, not all women obtain routine screening. The method used was a qualitative study exploring personal influences regarding Pap smears. Face-to-face interviews with 7 low-income African American women who do and do not obtain Pap smears (between 21 and 37 years of age) were conducted at a health department about their social influence, previous health care experience, and cognitive appraisal regarding Pap smears and cervical cancer. Women were found to be socially influenced by their family and their physician. Previous health care experience with the Pap and pelvic was perceived as negative. Cognitively, Pap smears were believed to test for sexually transmitted diseases, including HIV, and the women also felt that if one took good care of oneself it reduced the risk for cervical cancer. It was concluded that exploring beliefs associated with Pap smears and perceptions of vulnerability to cervical cancer and giving correct information and counseling may increase Pap smear screening in women.

Characteristics of schools of nursing operating academic nurse-managed centers.

Academic nurse-managed centers (ANMCs) can be important sites for addressing the tripartite mission of the academy. Yet, limited information about numbers of ANMCs and the schools sponsoring them is available. This paper presents an update on schools of nursing (SONs) operating ANMCs. A survey was sent to 683 deans and directors of baccalaureate and higher-degree SONs, with 565 responding (response rate: 83%). Ninety-two SONs indicated they had one or more ANMCs. The largest percentage of the SONs with ANMCs were classified as doctoral/research-intensive or extensive universities, a proportion much higher than the national percent of SONs in this category. Schools of Nursing were financially supporting centers at a lower percentage of actual costs than was reported in earlier studies, although grants continue to be a major source of funding. Academic nurse-managed centers are likely to be supported by SONs with substantial research, practice, faculty, and student resources. Overall, the national number of ANMCs seems stationary over the past two decades.

Satisfaction with a school-based teen health center: a report card on care.

Evaluations of the quality of School-Based Health Center (SBHC) care, both satisfaction and outcomes, have been developed by several state SBHC initiatives. However, few of these patient satisfaction surveys have been rigorously evaluated. An adolescent patient satisfaction based on a grading rubric familiar to the adolescents was developed and used to assess care at a nurse-managed teen health center. Satisfaction data on 190 encounters were collected in one SBHC using a report card rubric. The adolescent patients represented grades 6th through 8th, and were almost equally distributed between girls (55.9%) and boys (44.1%). This SBHC was a part of a university consortium of nurse-managed centers. Results demonstrated high satisfaction (approximately 3.7 out of 4) with care using a reliable tool (a = .84) designed for adolescents, which incorporated a grading rubric for the evaluation criteria. The nurse practitioner received high marks for listening to the students and treating the students with respect. Yet, statistical differences by grade level were found. The satisfaction tool was found to be reliable (alpha = .84) and consistent with adolescent's perspectives on satisfaction with health care. The study is the first published report that specifically examined student satisfaction with care in a nurse-managed SBHC. Overall satisfaction with care received high "grades" from both first time and repeat users, and from boys and girls.

Impact of academic nurse-managed centers on communities served.

PURPOSE: This paper presents findings from six community focus groups that addressed the impact of academic nurse-managed centers (ANMCs) on the overall community being served as well as the quality of care provided in the centers. DATA SOURCES: Experts in focus group methodology from a public health institute conducted the six focus groups at ANMCs from four universities in the Midwest. Discussions were guided by nine questions presented to each group. All groups were tape-recorded and transcribed. A total of 37 participants were recruited from the ANMCs and included patients and families, advisory board members, and local community organizations. CONCLUSIONS: Four themes were identified across the six focus groups: valuing patient-centered care, which included two subthemes-continuous specific provider and specific aspects of care; quality of care; increasing access to care/addressing the safety net; and evidence of outreach. IMPLICATIONS FOR PRACTICE: Findings from these focus groups verify that community members do "get it" in terms of the unique aspects of ANMCs. Participants were able to articulate the differences between nurse-managed care and other types of ambulatory primary care. The unique strengths of nurse practitioners were repeatedly articulated as well as the centers' outreach into the community.