- Nurse Practitioners as Primary Care Providers May Be a High-Value Solution to Increasing Access to Care for All Veterans
Investigators in this study assessed patient outcomes between primary care nurse practitioners (NPs) and MDs, including utilization, costs, and quality of care – one year after patient reassignment to a new primary care provider (due to a Veteran’s prior MD PCP leaving VA). Findings showed that compared to Veterans newly assigned to MDs, those newly assigned to NPs were less likely to use primary care and specialty care services – and incurred fewer hospitalizations. Further, Veterans assigned to NPs achieved similar quality of care in the management of chronic disease compared to those assigned to MDs. Differences in costs, clinical outcomes, and the receipt of diagnostic tests between NP and MD groups were not statistically significant. Findings suggest that the general use of nurse practitioners as primary care providers may be a high-value solution to increasing access to care for all Veterans. Also, comparable or better outcomes achieved at similar costs for patients across differing levels of comorbidity suggest NPs as primary care providers need not be limited to less complex patients.
Date: April 1, 2020
- JGIM Supplement Features VA Research on Care Coordination Both within VA and with Non-VA Healthcare Providers
In March 2018, a state-of-the-art (SOTA) conference on care coordination was jointly planned by VA HSR&D and the Offices of Primary Care, Community Care, Nursing Services, and Care Management and Social Work. The SOTA was organized into three workgroups: 1) measures and models of care coordination; 2) care coordination within the VA system; and 3) care coordination between VA and non-VA providers for care paid for by VA. SOTA participants included VA and non-VA health services researchers, clinicians, and policymakers. Funded by HSR&D, this JGIM Supplement presents recommendations from the SOTA, as well as original research papers on care coordination strategies within VA and between VA and non-VA providers.
Date: May 1, 2019
- Antihypertensive Deintensification Associated with Fewer Falls among Older VA Nursing Home Residents
This study sought to: 1) describe the frequency of antihypertensive de-intensification during scenarios suggesting over-aggressive treatment, 2) identify characteristics of residents associated with antihypertensive de-intensification, and 3) examine the association between antihypertensive de-intensification and subsequent falls. Findings showed that among Veterans with possibly over-aggressive antihypertensive treatment, just 11% underwent antihypertensive de-intensification. Among Veterans with low systolic blood pressure (SBP 80-100), antihypertensive de-intensification was associated with a lower risk of falling, but was not associated with risk of hospitalization or death. Among Veterans with possibly low SBP (101-120), antihypertensive de-intensification was associated with a higher risk of death, but not with risk of falling or hospitalization. In frail older adults, clinicians should repeatedly re-evaluate intensity of blood pressure management, taking into account the individual’s prognosis, goals of care, and an individualized estimate of the benefits and harms associated with the intensity of antihypertensive medication.
Date: December 1, 2018
- High-Risk Veterans with Access to Primary Care Intensive Management Receive Increased Outpatient Care without Increased Cost
Intensive Management (IM) models aim to proactively reduce complex patients’ deteriorations in health and resultant high-cost hospitalizations through interdisciplinary teams, care coordination, and support for care transitions. This study evaluated the impact of outpatient primary care IM programs on health care utilization and cost at five VA medical centers. Findings showed that Veterans receiving IM care had higher utilization of outpatient care without an increase in total costs (including costs of the IM program) or differences in mortality over a 12-month period. Veterans in IM care had greater use of outpatient services such as mental health/substance abuse care, home care, and palliative/hospice care both in person and by telephone. Increased outpatient costs were attributed to higher use of these services. Veterans in IM care had a statistically significant reduction in nursing home days and non-significant trends toward lower mean inpatient costs, number of inpatient stays, and number of hospital days. IM programs appeared to improve access to necessary outpatient services and improve engagement in care.
Date: June 19, 2018
- VA and Non-VA Nursing Homes Differ in CAUTI Prevention Methods
This study sought to compare infection prevention resources and practices between VA and non-VA nursing homes from 41 states that were participating as part of a national initiative to reduce catheter-associated urinary tract infections (CAUTIs), enhance frontline healthcare professional knowledge about infection prevention, and improve the safety culture in nursing homes. Findings showed that VA and non-VA nursing homes differed in their approach to CAUTI prevention: VA nursing homes reported more hours/week devoted to infection prevention-related activities (31 vs. 12 hours), and were more likely to have committees that reviewed healthcare-associated infections; VA nursing homes had substantially higher physician and nurse staffing to bed ratios compared with non-VA nursing homes; a higher percentage of VA nursing homes reported having 24-hour registered nurse supervision compared to non-VA nursing homes (96% vs. 56%); and most VA nursing home infection prevention programs were integrated within their VA acute care infection prevention programs, and they had more infection prevention related resources. In addition, a higher percentage of VA nursing homes reported tracking CAUTI rates (94% vs. 66%) and sharing CAUTI data with leadership and nursing personnel.
Date: December 5, 2016
- Study Compares Stroke Care in VA Community Living Centers with Private, VA-Contracted Nursing Homes
This study is part of a larger investigation comparing the use and functional outcomes between Veterans in VA community living centers (CLCs) and VA-contracted community nursing homes (CNHs). Findings showed that compared with Veterans residing at CNHs, Veterans residing at CLCs had fewer average rehabilitation therapy days (both adjusted and unadjusted), but were significantly more likely to receive restorative nursing care. For rehabilitation therapy, Veterans in CLCs had lower user rates (75% vs. 76%) and fewer observed therapy days (4.9 vs. 6.4) compared to Veterans in CNHs. For restorative nursing care, Veterans in CLCs had higher user rates (34% vs. 31%), more observed average care days (9.4 vs. 5.9), and more adjusted days for restorative nursing care.
Date: March 1, 2016
- Rehabilitation Settings for Veterans Following Hospital Discharge for Hip Fracture
This study explored the factors that impact choice of VA rehabilitation setting after acute hip fracture repair procedures. Findings showed that following hospitalization for hip fracture, nearly half (48%) of the Veterans in this study were discharged directly home – without VA-paid rehabilitation. Few Veterans (0.8%) were discharged with home health, with higher proportions discharged to a nursing home (15%), outpatient rehabilitation (19%), or inpatient rehabilitation (17%). Veterans with higher comorbidity scores were less likely to be discharged to inpatient rehabilitation. Veterans were more likely to be discharged to non-home settings if they had total functional dependence, had high American Society of Anesthesiology (ASA) class scores, had one or more surgical complications, or lived in counties with lower nursing home bed occupancy rates. Thus, it appeared that the most vulnerable patients were provided inpatient care. Surgical complications were the most significant predictor of discharge setting, but the availability of community resources also was an important predictor.
Date: January 1, 2014
- Publicly Reported Quality Ratings have Small but Positive Effect on Patient Choice of Nursing Home for Post-Acute Care
Patients were more likely to choose facilities with higher reported post-acute care quality related to resident pain control after public reporting was initiated; however, the magnitude of the effect was small. No changes in nursing home choice related to report card scores were seen in facilities not exposed to public reporting. A better pain score (less pain experienced by the patient) was associated with an increase in consumer demand after public reporting was initiated; for delirium, there was no significant effect, and for improved walking, the effect was unexpectedly negative. There was a differential response across patients by education level, which raises the possibility that the format and distribution of this information matters. Authors suggest that this information may be more influential if it is delivered to consumers in a more user-friendly format, or if it is delivered to patient advocates or surrogate decision-makers.
Date: January 10, 2012
- Evidence-Based Staffing Methodology to Predict Nurse Staffing Needs
This article describes a process used to identify indicators of nursing workload and develop an evidence-based nurse-staffing methodology that could be used to predict staffing needs and eventually link to nursing outcomes in the VA healthcare system. The final set of indicators included: 1) average length of stay (surrogate marker for patient severity of illness); 2) average number of medication doses administered daily; 3) percentage of patients with age >70; 4) percentage of patients with a BMI >25; 5) top three diagnostic categories on the unit (surrogate for complexity/scope of care required); 6) average daily census (patient volume and nursing workload); and 7) daily patient turnover (admissions, transfers, discharges). Following successful evaluation, the Office of Nursing Services introduced a national VA policy that directed all facilities to implement the new evidence-based, nationally standardized staffing methodology by September 2011. A formal evaluation will begin in October 2011.
Date: October 1, 2011
- Potential Problems with the Use of Antidepressants among Older Veterans Residing in VA Nursing Homes
This study examined the prevalence and patient/site-level factors associated with potential underuse, overuse, and inappropriate use of antidepressants among Veterans aged 65 years and older that were admitted to any one of 133 VA Community Living Centers (CLC, previously called Nursing Home Care Units). Findings suggest potential problems with the use of antidepressants in older Veterans that reside in VA CLCs. Overall, only 18% of antidepressant use was optimal. Of the 877 Veterans with depression, 25% did not receive an antidepressant, suggesting potential underuse. Among depressed Veterans who received antidepressants, 43% had potential inappropriate use due primarily to problems seen with drug-drug and drug-disease interactions. In addition, of the 2,815 Veterans who did not have depression, 42% were prescribed one or more antidepressants; of these, only 4% had an FDA-approved labeled indication, suggesting potential overuse. Also, the co-prescribing of antipsychotics (in patients without schizophrenia) among those without depression was associated with an increased risk of antidepressant overuse.
Date: August 1, 2011
- Nurse Case Management Decreases Cardiovascular Risk Factors among Veterans with Diabetes Compared to Usual Care
This study sought to determine if nurse case management could effectively improve rates of control for hypertension, hyperglycemia, and hyperlipidemia among Veterans with diabetes compared to usual care. Findings showed that involving a nurse case manager in the care of patients with diabetes can significantly improve the number of individuals achieving target values for glycemia, lipids, and blood pressure compared to usual care. In this study, a greater number of Veterans in the intervention group had all three outcome measures under control compared to Veterans in the usual care group. In addition, a greater number of Veterans in the nurse case management group achieved individual treatment goals for blood pressure, lipids, and blood sugar compared to Veterans receiving usual care. Observed differences between groups were likely mediated both by enhanced lifestyle changes and a greater intensity of pharmacological treatment among Veterans in the intervention group.
Date: June 2, 2011
- Pain Screening Implementation for Veterans Falls Short
This study included surveys of Veteran outpatients and nursing staff who screened for pain during normal vital sign intake. Investigators compared pain levels documented by the nursing staff with those reported by Veterans during the study survey. Findings show that despite a longstanding mandate, pain screening implementation falls short, and informal screening is common. Although pain was evaluated in all patient encounters, less than half of the Veterans reported that the nursing staff formally rated their pain. However, the majority of the time the nursing staff’s pain documentation matched the Veteran’s subsequent report within one point on the rating scale. When differences did occur, the nursing staff under-estimated pain in 25% of the cases, and overestimated pain in 7% of the cases. Veterans with PTSD or another anxiety disorder were almost twice as likely to report higher pain levels than those documented by the nursing staff. Additionally, nursing staff were less likely to underestimate pain when the patient self-reported excellent, very good, or good health status (relative to fair or poor health status).
Date: August 6, 2010
- Rates of Depression Rise among VA Nursing Home Residents
Prevalence rates for dementia and schizophrenia fluctuated moderately from 1990 to 2006, but rates for depression were substantially higher in 2006 than in 1998. Results also show that PTSD was more prevalent, while the prevalence of alcohol use disorders declined. The prevalence of serious mental illness (e.g., schizophrenia, bipolar and manic disorders) was relatively stable over this time period, except for increases among the oldest residents. Understanding recent changes in the prevalence of mental health disorders among VA nursing home residents can contribute to optimal planning to meet their treatment needs.
Date: April 1, 2010
- Addressing Psychosocial Needs of Cancer Patients
This Commentary discusses the nursing challenges of assessing and managing cancer-related distress, in addition to recommending assessment tools and further research. Measurement tools are available that are both well-established and feasible for nurses working within time-constrained environments.
Date: April 1, 2010
- More than One-Quarter of Elderly Individuals Require Surrogate Decision-Making Near the End of Life
Of the 3,746 elderly adults (non-Veterans) in this study, 26.8% required decision-making at the end of life and lacked decision-making capacity. Thus, surrogate decision-making was often required. Of those requiring surrogate decision-making, 67.6% had advance directives. Individuals who authored advance directives received care that was strongly associated with their preferences. And those who requested all care possible were far more likely to receive aggressive care compared to those who did not request it. Individuals with advance directives preferred limited and comfort care more than all care possible. Cognitive impairment, cerebrovascular disease, and nursing home status were associated with the need for decision-making and lost decision-making capacity before death; but these characteristics were so common (present in 65.3% of the study population) as to not be clinically useful risk factors.
Date: April 1, 2010
- Nursing Homes’ Disaster Response Activities Following Hurricanes Katrina and Rita
Hurricanes Katrina and Rita exposed significant flaws in the U.S. preparedness for catastrophic events – and in the nation’s capacity to respond to them. This article reviews VA’s response to these hurricanes, in regard to nursing home evacuation, and the literature on nursing home evacuation. Authors also propose a conceptual model to help guide decision-making for future evacuations.
Date: March 24, 2010
- Aggression is Common among Veterans with Dementia
Findings showed that 41% of Veterans with newly diagnosed dementia became aggressive within 24 months, corroborating the findings of previous studies that aggression is common in persons with dementia. The use of antipsychotic medications increased significantly in Veterans after they became aggressive, and this group also had a ten-fold greater occurrence of injuries. In addition, almost twice as many aggressive Veterans were admitted to nursing homes. There were no differences in rates of restraint use or in- and outpatient visits between Veterans who became aggressive and those who did not.
Date: March 1, 2010
- Nursing’s Role in Healthcare and Advancement in Evolving Healthcare Environment
In a recent national survey, although 77% of nurses reported that they were satisfied with their jobs, only 18% of nurses reported that they were actively engaged (defined as psychological commitment to job and workplace) in their work. Therefore, efforts to improve the clinical work environment, the safety culture, and the nursing education infrastructure are necessary. This article explores the opportunity for change by: 1) examining nursing’s history in professional practice and its journey as an evolving profession, and 2) mapping the growth of hospitals and the advancement of nursing’s role in the US, specifically in the context of the healthcare organization.
Date: January 1, 2010
- Drugs-to-Avoid Criteria for the Elderly have Limited Value
Drugs-to-avoid criteria are lists of drugs considered to be potentially inappropriate for the elderly due to adverse effects, limited effectiveness, or both. For example, the Centers for Medicare and Medicaid Services use a version of the criteria of Beers et al. in nursing homes, and the National Committee for Quality Assurance uses the criteria of Zhan et al. to compare the quality of U.S. health plans. This study compared the Beers and Zhan criteria with individualized expert assessment of patients’ medications in 256 elderly Veterans from the Iowa City VAMC who were taking five or more medications. Findings show that the drugs-to-avoid criteria performed poorly when used as quality measures to assess the current state of a patient’s drug therapy. For example, half or more of the drugs flagged by the Beers and Zhan criteria were not considered problematic upon individualized expert review. In addition, the Beers and Zhan criteria identified only 8-15% of drugs that experts judged to be problematic. Therefore, authors suggest that while these criteria are useful as guides for initial prescribing decisions, they are insufficiently accurate to use as stand-alone measures for the quality of prescribing.
Date: July 27, 2009
- Prescribing Discrepancies during Patient Transfer May Result in Adverse Drug Events
The objective of this study was to examine medication discrepancies related to adverse drug events (ADEs) in nursing home patients transferred to and from the hospital. Findings show that less than 5% of discrepancies caused ADEs, which is consistent with reviews that suggest only a small fraction of errors result in harm. Authors note that information about ADEs caused by medication discrepancies can be used to enhance measurement of care quality, identify high-risk patients, and inform the development of decision-support tools at the time of patient transfer.
Date: February 1, 2009
- Physicians May Need More Education about Long-Term Care Options for Veterans
The purpose of this study was to obtain information about VA long-term care (LTC) referrals that could be used to develop interventions that increase the likelihood of referrals to home and community-based services (HCBS) instead of institutional care. Findings indicate that physicians are often seen as having limited familiarity with HCBS options and tend to refer Veterans with LTC needs to nursing homes. Training physicians about LTC referral options, with particular focus on how HCBS can be used to meet Veteran and caregiver needs, may help to increase those referrals.
Date: February 1, 2009
- Veterans Using Home Healthcare have Higher Rates of Outpatient, Inpatient, and Nursing Home Care
Veterans receiving VA home health care in 2002 increased their absolute chance of using VA outpatient care by 3%, inpatient care by nearly 12%, and nursing home care by 5% in 2003. Moreover, although utilization rates were low, VA HHC users were about 10 times more likely to have used hospice, adult day health care, or respite care in the VA system than non-users.
Date: October 1, 2008
- Association between Nurse Staffing Levels and Patient Mortality in VA Hospitals
RN staffing was not significantly associated with in-hospital mortality for veterans with an ICU stay; however, increased RN staffing was significantly associated with decreased mortality among non-ICU patients. Continuing to estimate the effect of RN staffing and skill mix on patient outcomes using hospital-level data will provide poor estimates of outcome associations, such as in-hospital mortality.
Date: September 1, 2008
- VA Nurse Burnout and Patient Safety Outcomes
Among VA nurses at one Midwestern location, burnout was associated with perceptions of a less safe environment. While burnout was not associated with event-reporting behavior, it was negatively associated with reporting of near misses (mistakes that did not lead to adverse events). The finding that higher burnout was associated with lower incidence of near-miss reports is of concern because these reports are essential to addressing safety concerns in the environment.
Date: August 1, 2008