Churning the tides of care: when nurse turnover makes waves in patient access to primary care.

ABSTRACT

BACKGROUND: Team-based primary care (PC) enhances the quality of and access to health care. The Veterans Health Administration (VHA) implements team-based care through Patient Aligned Care Teams (PACTs), consisting of four core members a primary care provider, registered nurse (RN) care manager, licensed vocational nurse, and scheduling clerk. RNs play a central role they coordinate patient care, manage operational needs, and serve as a patient point of contact. Currently, it is not known how varying levels of RN staffing on primary care teams impact patient outcomes. OBJECTIVE: This study aims to empirically assess how the stability of RN staffing within team-based primary care affects patient access to care. METHODS: A retrospective database review using clinical and administrative data from the VHA over 24 months. Participants included 5,897 PC PACTs across 152 VHA healthcare facilities in the United States and its territories. The stability of personnel in the RN role was categorized as RN continuous churn, RN staffing instability and RN vacancy. All 3 categories were compared to teams with RN stability (i.e., same person in the role for the entire 24-month period). Access measures included average third-next-available appointment, established patient average wait time in days, urgent care utilization, emergency room utilization, and total inbound-to-outbound PC secure messages ratio. RESULTS: RN continuous churn within PACTs had a significant impact on third-next-available appointment (b = 3.70, p < 0.01). However, RN staffing instability and vacancy had no significant relationship with any of the access measures. Several risk adjustment variables, including team full-time equivalency, team stability, relative team size, and average team size, were significantly associated with access to health care. CONCLUSIONS: Teams are impacted by churn on the team. Adequate staffing and team stability significantly predict patient access primary care services. Healthcare organizations should focus on personnel retention and strategies to mitigate the impact(s) of continuous RN turnover. Future research should examine the relative impact of turnover and stability of other roles (e.g., clerks) and how team members adapt to personnel changes.