The Impact of Full Nurse Practitioner Scope of Practice Policy on Access to Care in the Privately Insured

ABSTRACT Esita Patel: The Impact of Full Nurse Practitioner Scope of Practice Policy on Access to Care in the Privately Insured (Under the direction of Dr. Barbara Mark) A greater understanding of how state-level nurse practitioner (NP) scope of practice (SOP) policies shape access to care is needed in the context of today’s rapidly expanding NP workforce. Prior work suggests a positive association between NP SOP and access to preventive services, however most studies fail to inform how implementing full NP SOP policy affects access over time. This study uses a difference-in-difference (DD) analysis to examine changes in access-related outcomes in states before and after implementation of full NP SOP policy (“intervention group”) compared to states with unchanged restricted NP SOP or unchanged full NP SOP policies (“comparison groups”). A retrospective analysis claims data from 2006-2015 was conducted using Truven Health MarketScan® Commercial Claims and Encounters Databases. Linear probability DD models were used to evaluate the effects of implementing full NP SOP on whether adults received an outpatient follow-up visit after hospitalization, an annual wellness exam, hyperlipidemia screening, or diabetes screening, as well as the impacts of full NP SOP implementation on all-cause emergency department encounters, all-cause hospitalizations, all-cause 30-day hospital readmissions, or hospitalizations for an acute ambulatory care sensitive condition in a one year period. Individual level covariates of age, gender, employment, rurality, and comorbidity were controlled for using a doubly robust propensity score strategy. Propensity score weighting was used to balance characteristics between treatment and control groups in the pre- and post- policy periods. Robust standard errors clustered at the state-level were used to adjust for heteroscedasticity and within-state correlation. Year and state fixed effects were used to adjust for time- and group- invariant confounders. The findings of this research indicated that in a commercially insured population, implementing full NP SOP does not consistently improve patients’ access to care outcomes compared to states with unchanged full or unchanged restricted NP SOP. Overall, the main analysis did not find a significant change in outpatient follow-up within 14 days of hospitalization or utilization of acute care services. The main model suggested a 3.0 percentage point increase in diabetes screenings (p<0.05) and a 4.0 percentage point decrease in annual wellness exams (p<0.01) following full NP SOP policy implementation compared to states with unchanged full and unchanged restrictive NP SOP, respectively. Moreover, there was variability in changes in outcomes following full NP SOP policy implementation by state. Although prior work suggested a positive association between NP SOP and access, this work consisted largely of cross-sectional comparisons between states with restricted versus full NP SOP. The results of this study highlight the importance of using longitudinal quasi-experimental approaches in future work to assess the relationship between NP SOP policy and access to care. The results of this study compared to previous work also suggests that NP SOP may have differential impacts on those who arguably already have adequate access to care, such as the commercially insured, versus underserved populations who do not.Doctor of Philosoph

Identifying Elements of the Business Case for Certified Nurse Midwife-led Birth Center Care through Systematic Review of Literature & Key Informant Interviews

Childbirth is repeatedly cited as the leading cause of hospitalizations and source of hospital costs in the United States (U.S.). Despite evidence suggesting that the certified nurse midwife-(CNM)-led free standing birth center (FSBC) care model provides safe, effective care, with less resource utilization and costs, as well as increased patient satisfaction for low risk births compared to traditional physician-led hospital based care, less than 0.5% of births in the U.S. occur through this model. The absence of a formal business case that demonstrates a financial return on investment for models shown to improve health care, such as the CNM-led FSBC care model in the U.S., is often cited as a reason for not implementing quality improving innovations in health care. Currently, there are no available criteria to guide the analysis of the business case for establishing and operating a free standing birth center. This paper aims to identify critical elements of a business case for the CNM-led FSBC model. A literature review of the CNM-led FSBC model in the U.S. was conducted applying principles of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement (Moher, Liberati, Tetziaff, & Altman, 2009). Exploratory semi-structured interviews were also conducted with two CNM and FSBC representatives. Results of the review and interviews were collectively analyzed using a directed content analysis approach guided by the Business Case for Quality Financial Model framework (Pink, Thomas, Kilpatrick, & Brown, 2005) to identify essential elements to consider when developing a business case for CNM-led FSBCs, including financial factors involved in initial investments and cash flows. This information may allow stakeholders to better understand factors necessary to consider when starting or operating a CNM-led FSBC.Bachelor of Scienc

A Qualitative Evaluation of Advances in Emergency Department Opioid Use Disorder Care in Michigan

The United States opioid epidemic claims the lives of tens of thousands of Americans each year due to opioid overdose. Hospital emergency departments (EDs) have been essential in combatting the crisis by stabilizing patients who are experiencing an overdose and other symptoms of their opioid use disorders (OUD). Over time, EDs have also become more involved in providing other addiction treatment services, such as prescribing and administering medications for opioid use disorder (MOUD) and referring their patients to outpatient behavioral health care providers for follow-up treatment. Policymakers have been essential in driving EDs to expand the scope of their addiction medicine services and referrals by creating specialized programs that provide incentivizes to participating hospitals.The following report summarizes advances in opioid use disorder care within EDs in 19 hospitals across 8 health systems in Michigan. These hospitals participated in an initiative created by the Community Foundation for Southeast Michigan (CFSEM) in collaboration with the Michigan Opioid Partnership (MOP), a public-private collaborative with a mission to reduce opioid overdoses in Michigan by improving the access and quality of prevention, treatment, harm reduction, and recovery services. The initiative was supported by State Opioid Response grants from the Michigan Department of Health and Human Services. Vital Strategies, a global public health organization that helps governments strengthen public health, provided support, technical assistance, and resources to improve hospital coordination and designed the evaluation. Specifically, hospitals were provided funding by CFSEM to improve OUD care training, coordination, delivery, and quality in their EDs. Hospitals and health systems funded by CFSEM included the University of Michigan Health System (Michigan Medicine hospital), Trinity Health (Mercy Health Muskegon, Mercy Health St. Mary, St. Joseph Mercy - Ann Arbor, St. Joseph Mercy Chelsea, St. Joseph Mercy Livingston, St. Joseph Mercy Oakland), Henry Ford Health Systems (Henry Ford – Main, Henry Ford - Wynadotte/ Brownstown), Beaumont Health Systems (Beaumont - Royal Oak, Beaumont – Troy, Beaumont – Wayne), Ascension (Ascension St. John Hospital, Ascension Genesys Hospital), Munson Healthcare (Munson Medical Center - Traverse City, Sparrow Health System (Sparrow Hospital - Lansing), Spectrum Health (Spectrum Health Butterworth), War Memorial, and Hurley Medical Center. After receiving funding, hospitals created work plans related to improving opioid use disorder care in their EDs, including by increasing their number of employed X-waivered providers, integrating clinical tracking and support tools into electronic medical records, and connecting patients with behavioral health care providers in the community to establish treatment continuity (i.e., "warm handoffs"). Researchers with the Bloomberg Overdose Prevention Initiative at the Johns Hopkins Bloomberg School of Public Health evaluated hospital improvement in these areas using surveys and qualitative interviews with participants

Utility of the Business Case for Quality Approach in Healthcare: Practice & Policy Implications from an Integrated Review

Background: As the scrutiny on healthcare quality and costs intensifies, the need to align healthcare quality enhancing initiatives (QEIs) with the finances that facilitate these QEIs becomes important to QEI buy‐in, uptake, and sustainability from stakeholders. The business case (BC) Approach can serve as a strategic tool to this. The absence of a BC for a QEI can derail a QEI. Purpose: This study evaluates published BCs In nursing to synthesize current uses, gaps, and implications of the BC approach in healthcare. Study Design: An integrative review was conducted using Whifemore and Knafl’s (2005) methodology16. E--‐databases (CINAHL, Pubmed, Business Source Premier, and ProQuest Central) were searched for studies from 2003--‐2016 using a comprehensive strategy. All data were extracted into a standardized template and results were collectively analyzed for and categorized by common themes and conclusions, based on Reiter et al.’s (2007) 11 steps for developing a BC for quality17. We used these data to diagram the uses of the BC in healthcare. Conclusions: Few BC analyses exist in healthcare literature. • There were inconsistencies in the use of the term “business case” and strategies used to conduct and present them. • The BC is a powerful but underutilized tool that provides stakeholders systematic evidence to support or reject a QEI in healthcare

Impact of Nurse Practitioner Scope of Practice Regulation on Access to Care: Implications for Policy & Research from a Systematic Review

Background: Policy reform aimed at removing state-level scope of practice (SOP) restrictions for nurse practitioners (NPs) is debated as a strategy to increase access to care because NPs are the fastest growing primary care (PC) provider, are more likely to provide care for select underserved populations than other provider types, and provide high-quality cost-effective care12,13,14,15. Research Objective: This study was conducted to systematically review literature on the impact of state-level SOP regulations for NPs on access to health care services, as defined by Aday and Andersen’s (1974) Framework for the Study of Access to Medical Care11 Study Design: We searched CINAHL, Pubmed, And EMBASE for studies published from 2006--‐2016 using a comprehensive keyword search strategy. The search yielded 500 studies, of which 8 met inclusion criteria. 2 additional studies were added after the initial review was conducted, yielding 10 total studies. All data were extracted into a standardized template, assessed for themes and categories, and guided by Aday & Andersen’s Framework (1974)11. This framework was further used to examine access to care relationships across reviewed studies. PRIMSA guidelines were followed. Conclusions: The results from this review largely support that less restrictive NP SOP regulations is associated with increased access to care. However, additional research that uses longitudinal methods would better inform recommendations for policy efforts surrounding state level NP SOP regulation. Results: CHARACTERISTICS OF THE HEALTH DELIVERY SYSTEM: NPs were more likely to practice in states with the least SOP restrictions1,3,4,8. Furthermore, there was greater growth in the number of NPs in states with the least SOP regulations4,8. CHARACTERISTICS OF THE POPULATION AT RISK: Some studies report that in states with the least restrictive NP SOP regulations, NPs were more likely to work in PC in rural and high-poverty areas and accept Medicaid1,3. Contrastingly, one study found that rural areas and areas with high poverty rates have fewer NPs, and suggested that this may be due to socioeconomic environment impacting provider reimbursement8. PATIENT LEVEL OUTCOMES: UTILIZATION OF HEATH SERVICES & PATIENT REPORTED QUALITY OF CARE: Patients in states with the least restrictive NP SOP regulations were more likely to use certain preventative services5,6,9,10, have an NP as their PC provider4, have referrals to MDs5, have decreased rates of avoidable hospitalizations, hospital readmissions within 30 days discharge from rehabilitation, hospitalizations of nursing home patients7, emergency room use10, and increased overall health outcomes7. Contrastingly, one study with significant missing data stated that patient reported usual source of care, wait times, and difficulties accessing care were not improved with increased NP SOP regulation2. Furthermore, another study reported that a larger supply of NPs, without considering other state and patient level factors, did not significantly affect healthcare utilization9