DiversityNursing Blog

Phil Galewitz

www.usatoday.com 

With her children grown and husband nearing retirement, Amy Reynolds was ready to leave behind snowy Flagstaff, Ariz., to travel but she wasn't ready to give up her nursing career.

She didn't have to.

For the past three years, Reynolds, 55, has been a travel nurse – working for about three months at a time at hospitals in California, Washington, Texas and Idaho, among other states. Her husband accompanies her on the assignments. "It's been wonderful," she said in May after starting a stint in Sacramento. "It's given us a chance to try out other parts of the country."

Reynolds is one of thousands of registered nurses who travel the country helping hospitals and other health care facilities in need of experienced, temporary staff.

With an invigorated national economy and millions of people gaining health coverage under the Affordable Care Act, demand for nurses such as Reynolds is at a 20-year high, industry analysts say. That's meant Reynolds has her pick of hospitals and cities when it's time for her next assignment. And it's driven up stock prices of the largest publicly traded travel-nurse companies, including San Diego-based AMN Healthcare Services and Cross Country Healthcare of Boca Raton, Fla.

"We've seen a broad uptick in health care employment, which the staffing agencies are riding," said Randle Reece, an analyst with investment firm Avondale Partners. He estimates the demand for nurses and other health care personnel is at its highest level since the mid-1990s.

Demand for travel nursing is expected to increase by 10% this year "due to declining unemployment, which raises demand by increasing commercial admissions to hospitals," according to Staffing Industry Analysts, a research firm. That trend is expected to accelerate, the report said, because of higher hospital admissions propelled by the health law. 

Improved profits — particularly in states that expanded Medicaid — have also made hospitals more amenable to hire travel nurses to help them keep up with rising admissions, analysts say.

At AMN Healthcare, the nation's largest travel-nurse company, demand for nurses is up significantly in the past year: CEO Susan Salka said orders from many hospitals have doubled or tripled in recent years. Much of the demand is for nurses with experience in intensive care, emergency departments and other specialty areas. "We can't fill all the jobs that are out there," she said.

Northside Hospital in Atlanta is among hospitals that have recently increased demand for travel nurses, said David Votta, manager of human resources. "It's a love-hate relationship," he said. From a financial viewpoint, the travel nurses can cost significantly more per hour than regular nurses. But the travel nurses provide a vital role to help the hospital fills gaps in staffing so they can serve more patients. 

Northside is using 40 travel nurses at its three hospitals, an increase of about 52% since last year. The system employs about 4,000 nurses overall. 

Historically, the most common reason why hospitals turn to traveling nurses is seasonal demand, according to a 2011 study by accounting firm KPMG. Nearly half of hospitals surveyed said seasonal influxes in places such as Arizona or Florida, where large numbers of retirees flock every winter, led them to hire traveling nurses. 

Though there have been rare reports of travel nurses involved in patient safety problems, a 2012 study by researchers at the University of Pennsylvania published in the Journal of Health Services Research found no link between travel nurses and patient mortality rates. The study examined more than 1.3 million patients and 40,000 nurses in more than 600 hospitals. "Our study showed these nurses could be lifesavers. Hiring temporary nurses can alleviate shortages that could produce higher patient mortality," said Linda Aiken, director of the university's Center for Health Outcomes and Policy Research. The study was funded by the National Institutes of Health and the American Staffing Association Foundation.

The staffing companies screen and interview nurses to make sure they are qualified, and some hospitals, such as Northside, also make their own checks. Nurses usually spend a couple days getting orientated to a hospital and its operations before beginning work. They have to be licensed in each state they practice in, although about 20 states have reciprocity laws that expedite the process.

Cherisse Dillard, a labor and delivery room nurse, has been a traveler for nearly a decade. In the past few years, she's worked at hospitals in Chicago, Dallas, Houston, Pensacola and the San Francisco area.

While delivering a baby is relatively standard practice, she said she makes it a practice at each new hospital to talk to doctors and other staff to learn what their preferences are with drugs and other procedures. Dillard, 46, often can negotiate to be off on weekends and be paid a high hourly rate. "When the economy crashed in 2008, hospitals became tight with their budget and it was tough to find jobs, but now it's back to full swing and there are abundant jobs for travel nurses," she said.

SABRINA TAVERNISE

When it came time to have the baby, Shirita Corley was alone. Her mother was at the casino, her sister was not answering her cellphone, her boyfriend had disappeared months earlier, and her father she had not seen in years.

So she got in her green Chevy TrailBlazer and drove herself to the hospital.

“I feel so down,” she texted from her hospital bed. “I’m sick of these deadbeats. I’m sick of having to be so strong.”

The message went not to a friend or family member, but to a nurse, Beth Pletz. Ms. Pletz has counseled Ms. Corley at her home through the Nurse-Family Partnership, which helps poor, first-time mothers learn to be parents.

Such home visiting programs, paid for through the Affordable Care Act, are at the heart of a sweeping federal effort aimed at one of the nation’s most entrenched social problems: the persistently high rates of infant mortality. The programs have spread to some 800 cities and towns in recent years, and are testing whether successful small-scale efforts to improve children’s health by educating mothers can work on a broad national canvas.

Home visiting is an attempt to counter the damaging effects of poverty by changing habits and behaviors that have developed over generations. It gained popularity in the United States in the late 1800s when health workers like Dr. S. Josephine Baker and Lillian Wald helped poor mothers and their babies on the teeming, impoverished Lower East Side of Manhattan. At its best, the program gives poor women the confidence to take charge of their lives, a tall order that Ms. Pletz says can be achieved only if the visits are sustained. In her program, operated here by Le Bonheur Children’s Hospital, the visits continue for two years.

It is Ms. Pletz’s knack for listening and talking to women — about misbehaving men, broken cars, unreliable families — that forms the bones of her bond with them.

She zips around Memphis in her aging Toyota S.U.V. with a stethoscope dangling from the rearview mirror. Her cracked iPhone perpetually pings with texts from her 25 clients. Most of them are young, black, poor and single. Few had fathers in their lives as children, and their children are often repeating the same broken pattern.

“I was lost, going from house to house,” recalled Onie Hayslett, 22, who was homeless and pregnant when she first met Ms. Pletz two years ago. Her only shoes were slippers. “She brought me food. That’s not her job description, but she did it anyway. She really cares about what’s going on. I don’t have many people in my life like that.”

Infant mortality rates in the United States are about the same as those in Europe in the first month of life, a recent study found, but then become higher in the months after babies come home from the hospital — a period when abuse and neglect can set in. (The study adjusted for premature births, which are also higher in the United States partly because of poverty. They were kept out of the study, researchers said, because the policies to reduce them are different.)

In Memphis, where close to half of children live in poverty, according to census data, the infant mortality rate has long been among the country’s highest. Sleep deaths — in which babies suffocate because of too much soft bedding or because an adult rolls over onto them — accounted for a fifth of infant deaths in the state, according to a 2013 analysis of death certificates by the Tennessee Department of Health.

When Ms. Pletz recently visited Darrisha Onry, 21, she saw Ms. Onry’s week-old child, Cedveon, lying beside her on a dark blue couch. The room was warm, small and crowded with a large living room set, a glass table, porcelain statues of dogs and an oversize cage holding two tiny, napping puppies.

“Where is he sleeping?” Ms. Pletz asked.

Cedveon started to cry, and Ms. Onry walked out of the room to make his bottle.

“The safest place for him is alone by himself on his back in his crib,” Ms. Pletz said, scooping up Cedveon, who had launched into a full-throated squall.

A little later, Ms. Pletz said, "You know never to shake the baby, right?”

Ms. Onry nodded.

Ms. Pletz continued: “Nerves get shot and sometimes people lose their cool. If that happens, just put him on his back on a bed and close the door, and take a little rest away from him.”

The program is unusual because it is based on a series of clinical trials much like those used to test drugs. In the 1970s, a child development expert, Dr. David Olds, began sending nurses into the homes of poor mothers in Elmira, N.Y., and later into Memphis and Denver. The nurses taught mothers not to fall asleep on the couch with their infants, not to give them Coca-Cola, to pick them up when they cried and to praise them when they behaved. The outcomes were compared with those from a similar group of women who did not get the help.

The results were startling. Death rates in the visited families dropped not just for children, but for mothers, too, when compared with families who did not get the services. Child abuse and neglect declined by half. Mothers stayed in the work force longer, and their use of welfare, food stamps and Medicaid declined. Children of the most vulnerable mothers had higher grade-point averages and were less likely to be arrested than their counterparts.

The program caught the attention of President Obama, who cited it in his first presidential campaign. His administration funded the program on a national scale in 2010. So far, the home visits have reached more than 115,000 mothers and children. States apply for grants and are required to collect data on how the families fare on measures of health, education and economic self-sufficiency. Early results are expected this year.

“The big question is, can the principle of evidence be implemented in a large federal program?” said Jon Baron, president of the Coalition for Evidence-Based Policy, a nonprofit group in Washington whose aim is to increase government effectiveness in areas including education, poverty reduction and crime prevention. “And if so, will it actually improve health?”

Experts say federal standards are too loose and have allowed some groups with weak home visiting programs to participate, even if they show effects on only trivial outcomes that have no practical importance for a child’s life. Congress should fix the problem, Mr. Baron said, warning that the program in its current state is “a leaky bucket.”

“If left unchanged, essentially anyone will figure out how to qualify,” he said.

Its future is not assured. Funding for the home visiting initiative runs out as early as September for some states, and if Congress does not reauthorize it this month, programs may stop enrolling families and the $500 million the Obama administration has requested for 2016 will not be granted. Last week, its supporters urged Congress to extend it.

In Tennessee, where home visiting programs have bipartisan support, infant mortality is down by 14 percent since 2010, and sleep deaths dipped by 10 percent from 2012 to 2013. State officials credit a multitude of policies, including the home visits.

Ms. Pletz worries that she has helped only a handful of her clients truly improve their lives. But Ms. Corley, 28, the mother who drove herself to the hospital, said Ms. Pletz, who has been visiting her for two years, had made a difference. She “has been my counselor, my girlfriend, my nurse,” Ms. Corley said. Ms. Pletz helped her cope with the disappearances of her children’s fathers, taught her to recognize whooping cough and pushed her to set career goals, she said.

“She knows more about me than my own family does,” Ms. Corley said. “I feel like I’ve grown more wise. I feel stronger for sure.”

The morning after Ms. Corley gave birth, Ms. Pletz brought her breakfast: eggs, flapjacks and bacon. The new baby, Daniel, lay in a clear plastic crib next to Ms. Corley’s hospital bed, and the two women talked over his head like old friends.

“Can I pick him up?” Ms. Pletz asked.

Ms. Corley replied: “I think he’s waiting on it.”

Source: www.nytimes.com

The Health Insurance Marketplace open enrollment launch on October 1, 2013 spurred discussion about the influx of newly insured patients and the shortage of primary care professionals. Nursing@Simmons, an online Master of Science in Nursing program for aspiring Family Nurse Practitioners, created an infographic to illustrate the state of primary and preventive health care in the U.S. and the role nursing professionals hold. This infographic provides a snapshot of what has happened in the years since the Affordable Care Act was conceptualized and enacted, in addition to showing how nurse practitioners are contributing to primary care.

Share the infographic below to raise awareness about the role that Family Nurse Practitioners play in health care reform under the Affordable Care Act.

Source: Simmons Nursing

As seen in The New York Times    

There is already a shortage of doctors in many parts of the United States. The expansion of health care coverage to millions of uninsured Americans under the Affordable Care Act will make that shortage even worse. Expanding medical schools and residency programs could help in the long run.

But a sensible solution to this crisis — particularly to address the short supply of primary care doctors — is to rely much more on nurse practitioners, physician assistants, pharmacists, community members and even the patients themselves to do many of the routine tasks traditionally reserved for doctors.

There is plenty of evidence that well-trained health workers can provide routine service that is every bit as good or even better than what patients would receive from a doctor. And because they are paid less than the doctors, they can save the patient and the health care system money.

Here are some initiatives that use non-doctors to provide medical care, with very promising results:

PHARMACISTS A report by the chief pharmacist of the United States Public Health Service a year ago argued persuasively that pharmacists are “remarkably underutilized” given their education, training and closeness to the community. The chief exceptions are pharmacists who work in federal agencies like the Department of Veterans Affairs, the Department of Defense and the Indian Health Service, where they deliver a lot of health care with minimal supervision. After an initial diagnosis is made by a doctor, federal pharmacists manage the care of patients when medications are the primary treatment, as is very often the case.

They can start, stop or adjust medications, order and interpret laboratory tests, and coordinate follow-up care. But various state and federal laws make it hard for pharmacists in private practice to perform such services without a doctor’s supervision, even though patients often like dealing with a pharmacist, especially for routine matters.

NURSE PRACTITIONERS In 2012, 18 states and the District of Columbia allowed nurse practitioners, who typically have master’s degrees and more advanced training than registered nurses, to diagnose illnesses and treat patients, and to prescribe medications without a doctor’s involvement.

Substantial evidence shows that nurse practitioners are as capable of providing primary care as doctors and are generally more sensitive to what a patient wants and needs.

In a report in October 2010, the Institute of Medicine, a unit of the National Academy of Sciences, called for the removal of legal barriers that hinder nurse practitioners from providing medical care for which they have been trained. It also urged that more nurses be given higher levels of training, and that better data be collected on the number of nurse practitioners and other advance practice nurses in the country and the roles they are performing. Tens of thousands will probably be needed, if not more.

Mary Mundinger, dean emeritus of Columbia University School of Nursing, believes highly trained nurses are actually better at primary care than doctors are, and they have experience working in the community, in nursing homes, patients’ homes and schools, and are better at disease prevention and helping patients follow medical regimens.

RETAIL CLINICS Hundreds of clinics, mostly staffed by nurse practitioners, have been opened in drugstores and big retail stores around the country, putting basic care within easy reach of tens of millions of people. The CVS drugstore chain has opened 640 retail clinics, and Walgreens has more than 350. The clinics treat common conditions like ear infections, administer vaccines and perform simple laboratory tests.

A study by the RAND Corporation of CVS retail clinics in Minnesota found that in many cases they delivered better and much cheaper care than doctor’s offices, urgent care centers and emergency rooms.

TRUSTED COMMUNITY AIDES One novel approach trains local community members who have experience caring for others to deliver routine services for patients at home. Two pediatric Medicaid centers in Houston and Harrisonburg, Va., have tested this concept to see if it can reduce the cost of home care and avoid unnecessary admissions to a clinic or hospital.

The aides are trained to consult with patients over the phone by asking questions devised by experts. A supervising nurse makes the final decisions on the care a patient requires. The community aide may visit the patient, provide care in the home and send photos or videos back to the supervising nurse by cellphone.

The aides are typically paid about $25,000 a year, according to an article in Health Affairs by the pilot study’s leaders. The study concluded that the program would have averted 62 percent of the visits to a Houston clinic and 74 percent of the emergency room visits in Harrisonburg.

The aides cost $17 per call or visit, compared with Medicaid payment rates of $200 for a clinic visit in Houston and $175 for an emergency room in Harrisonburg.

SELF-CARE AT HOME A program run by the Vanderbilt University Medical Center and its affiliates lets patients with hypertension, diabetes and congestive heart failure decide whether they want a care coordinator to visit them at home or prefer to measure their own blood pressure, pulse or glucose levels and enter the results online, where the data can be immediately reviewed by their primary care doctor. The patient could consult by phone or e-mail with a nurse about his insulin dosage, but there would be no need for a costly visit to a doctor.

Taking this idea a step further, a hospital in Sweden, prodded by a kidney dialysis patient who thought he could do his own hemodialysis better than the nursing staff, allowed him to do so and then teach other patients, according to the Institute for Healthcare Improvement, a nonprofit organization in Cambridge, Mass. Now most dialysis at that hospital is administered by the patients themselves. Costs have been cut in half, and complications and infections have been greatly reduced.

HEALTH REFORM LAW The Affordable Care Act contains many provisions that should help relieve the shortage of primary care providers, both doctors and other health care professionals.

It provides money to increase the number of medical residents, nurse practitioners and physician assistants trained in primary care, yielding more than 1,700 new primary care providers by 2015. It offers big bonuses for up to five hospitals to train advanced practice nurses and has demonstration projects to promote primary care coordination of complex illnesses, incorporating pharmacists and social workers in some cases. And it offers financial incentives for doctors to practice primary care — like family medicine, internal medicine and pediatrics — as opposed to specialties.

These are all moves in the right direction, but they will need to be followed by even bigger steps and protected from budget cuts in efforts to reduce the deficit.