Below is the uncorrected machine-read text of this chapter, intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text of each book. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
CHATTIER VI ADev~ahng Nursing Shortages in Medically Underserved Areas and Among Underserved Populations In earlier chapters this report has dealt with issues of aggregate supply and demand for nursing as a whole and for nurses with different levels of educational preparation. Another distributive aspect of the supply problem was posed in the second of the congressional questions that occasioned this study: "What are the reasons nurses do not serve in medically underserved areas and what actions could be taken to encourage nurses to practice in such areas?" The committee viewed these issues as being more extensive than would be implied by statutory or regulatory definitions of the term "medically under- served areas." We believed that this question called for an exploration of the problems of maldistribution as they affect certain geographic areas, certain population groups, and certain types of facilities that experience chronic nurse shortages resulting in underservice to large numbers of patients. This chapter focuses on availability of the services of nurses to residents of inner cities and rural areas, to minority ethnic groups and elderly citizens, and to patients in public hospitals and nursing homes. There are commonalities among the geographic areas, population groups, and institutions identified as suffering from the maldistribution of nursing personnel. For all of them, indications of severe unmet nursing needs persist and are not likely to be self-correcting under foreseeable market conditions. The magnitude of the problem is suggested by estimates that 20 million residents of inner city and rural areas are without a regular source of primary care,1 and that approximately 12-15 million Americans are "structurally underserved"--that is, their difficulties of access to nursing services are tougher and more complicated than those of the rest of the population.2 This chapter first describes the nature and consequences of underservice and examines recent attempts to attract nurses to underserved areas and increase the representation in nursing of economically disadvantaged individuals. Nursing service problems of the inner cities and the elderly are then discussed. The chapter concludes with a look at the functions of nurse practitioners in alleviating problems of underservice. 157
158 Some Reasons for Areas of Underservice Lack of access to preventive, primary, and acute care services by people living in inner cities and in rural communities remains one of the nation's most pressing health problems. It ranks with the lack of access to effective preventive and maintenance care of the nation's elderly, large numbers of whom may as a result become untimely afflicted with worsening chronic conditions that lead to long-tenm institutionalization. Among all underserved populations, barriers to care are created by lack of adequate financing, transportation problems, lack of health care facilities, and lack of health manpower to staff facilities or provide services outside health care institutions. The obvious explanation of nursing and other health manpower shortages lies in the nature of the nation's health care financing arrangements. Inadequate public or private coverage to pay for services to very large numbers of low-income people results in lack of programs or lack of access to programs and facilities that can meet their medical and other health care needs. Inadequate financing and the resulting inappropriate services make it unlikely that nurses will seek or be able to find employment, even though they may wish to work in an underserved area or with underserved people. We believe that solutions to the problems of medical underservice eventually will require a long-range restructuring not only of the nation's health care financing, but also of health services delivery arrangements. Other public commissions and studies have come to similar conclusions. While it was not within our purview to address these fundamental problems, the study necessarily became concerned with their implications as principal factors in the maldistribution of nursing personnel. In this context, the committee has responded to the request for suggestions likely to help alleviate existing nurse shortages in medically underserved areas. The Nature and Consequences of Underservice Many rural and semi-rural areas, where 30 percent of the nation's population lives, are characterized by low population density, disproportionate numbers of poor and elderly, vast distances, and small hospitals.3 Providing health care in these circumstances presents multiple problems. Most nurses are employed by hospitals, nursing homes, physicians, and health departments. Therefore, most nursing care depends on the presence of such employers, but they are not found in many remote communities. Approximately 500 of the nation's more than 3,000 counties currently have no hospital.4 The economics of supplying adequate levels of health services to poor and remote populations and the heavy workload associated with being a solo practitioner make remote and poor rural areas unattractive to physician practice. In
159 1979, 143 counties had no active physician, federal or non-federal, engaged in patient care.5 These and~other factors result in employed nurse-to-population ratios that are usually much lower for rural than for urban areas. The 1977-1978 Inventory of Registered Nurses showed that the ratio of employed registered nurses (RNs) per 100,000 population ranged from a low of 268 in Arkansas, a largely rural state, to 885 in urban District of Columbia. Moreover, such comparisons fail to reveal the often substantial pockets of underservice that frequently exist in a state. Among the areas alone that were not standard metropolitan statistical areas (SMSAs), this ratio ranged from a low of 162 in Louisiana to a high of 892 in New Hampshire. Vacancy rates for nurses in hospitals are not markedly different in small and large institutions, but hospitals in non-SMSAs have more recruitment problems than do their urban counterparts.6 State studies and testimony from hospital representatives have noted the special difficulties associated with nurse shortages in rural areas. In testimony before the Senate Finance Committee, one witness commented that there was an immediate need for at least 300 RNs in 61 Montana hospitals, most of which are in rural areas. He also noted that while a nurse vacancy in a large hospital may not be really crucial, "when a small facility loses one nurse, that's a crisis situation."7 Further, he observed that Montana's small rural hospitals consistently upgrade their salary and fringe benefits to meet and, in same cases, exceed those of the larger facility in order to attract nurses to their hospitals. Other testimony suggests some factors that detract nurses from rural service. "Rural nurses are asked to assume greater responsibility, are often on call 24 hours a day. . . . Rural public health nurses find their salaries and working conditions determined by county commissioners who are often more concerned with building and maintaining roads and bridges than quality health care. Feeling frustrated...they leave their chosen profession."8 Additionally, fluctuations in patient census tend to make some rural hospitals unreliable employers. And where the absence of other providers puts major responsibility for health care on public health nurses 5 the level of funding may support only a minimal number.9 These problems and others lie behind the fact that in rural areas 21 percent of black children and 14 percent of white children had no physician visits in 1981 compared with 10 percent and 9 percent, respectively, of children in SMSAs.10 Residents of non-metropolitan areas are also less likely to have preventive care and more likely to spend more than 30 minutes traveling to a physician visit and to experience longer waits once there. Seventeen percent of physician visits by residents of non-SMSAs occurred in metropolitan areas. Nursing shortages in rural areas are only one aspect of the problem of underservice. Minority, immigrant, and other low-income populations in many urban areas of the nation also can lack access to health care. Large concentrations of these people are found in inner city areas, where nursing and other health care services present
160 particular problems.* Although the gap in utilization of health care between the poor and nonpoor in both urban and rural areas that existed quite generally prior to the 1960s almost closed between the mid-1960s and 1980, serious problems of access nevertheless remain, particularly in the settings where poor and minority people--notably blacks and Hispanics--receive care.12 For example, a study in Boston found a 4 percent decline in the number of inner-city residents who had a personal physician between 1975 and 1981, despite a 7 percent increase in the nationwide physician-to-population ratio during this period.13 Differences between the health status of underserved populations (whether rural, urban, poor, or minority) and better served groups also indicate unmet needs for health care. Household interview surveys conducted by the National Center for Health Statistics in 1979 found that consistently greater proportions of residents outside of the standard metropolitan statistical areas than SMSA residents reported health conditions that made them unable to carry on major activities of daily living. More than 14 percent of the non-SMSA residents rated their health as only fair or poor, compared with 11.4 of the SMSA residents.14 People in federally designated medically underserved rural areas have 24 percent higher hospital utilization, 33 percent more disability days, and 22 percent more chronic limitations than do those in rural areas not so designated.+ Mexican-American migrant agricultural workers are said to have a much lower life expectancy and higher rates of illness than does the population as a whole, but scant data are yet available to describe their health status. Educational Outreach Since the mid-1960s the federal government, the states, and higher education systems have adopted various strategies designed to alleviate identified nurse shortages in medically underserved areas. . ~Currently, blacks constitute 28 percent of the population of large central cities compared with 12 percent of the total United States population, and Hispanics constitute It percent as opposed to 5 percent. A disproportionate number of inner-city residents have incomes below the poverty level, 17 percent versus 12 percent of the total United States population.15 Cover the years the federal government has defined geographic areas of underservice using a variety of criteria. The areas have been variously delineated as Medically Underserved Areas, Health Manpower Shortage Areas and Nurse Shortage Areas. Many technical problems have been encountered in attempting to define these areas of underservice so as to accomplish program objectives. This report does not address these technical issues but notes that discussions concerning definitions of underservice are continuing.
161 One such strategy has been to offer financial incentives through educational loan repayment arrangements designed to attract nurses to serve in such areas. The strategy implies a hope that an appreciable proportion of such nurses will remain in the shortage area after their service obligation has been met, but there is no evidence either At the federal level, examples include programs under the Nurse Training Act (NTA) of 1964 and subsequent amendments, and National Health Service Corps authorizations. The NTA Nursing Loan Repayment Program offers repayment of a portion of an RN's educational loan in return for 2 or 3 years of service in a designated nurse shortage area (Appendix 2~. Between 1974 and 1981 approximately 219,000 nurses received educational loans but only 128 accepted the option of service in return for loan repay- ment. The failure of the program has been commonly attributed to the more favorable teems offered by the Federal Nursing Loan Cancellation Program, which allowed cancellation of up to 85 percent of an - education loan for practicing nurses working in a public or nonprofit hospital, health center, or other health care agency for more than 1 year, regardless of location or population served.16 The National Health Service Corps Scholarship Program also used the incentive of repayment of educational loan in return for a service obligation. Of the 564 nurses awarded scholarships, almost all met not collected to indicate the service obligations, but data were whether any were staying in the shortage area after their obligated service e The Nurse Practitioner Traineeship Program under NTA described in Chapter V also offered payback incentives for service in shortage areas. Again, because the current status of 50 percent of the traineeship recipients is unknown, the program cannot be evaluated. Nurse education programs are not required to keep records or report on where their graduates practice. A second strategy--facilitating nurse education for those most likely to work in underserved areas--is built on the assumption that people who already live in such areas are more likely to remain than are those attracted for a limited tour of service. Evidence supports this hypothesis. Feldbaum's 1977-1978 survey found that nurses who grew up in rural areas were the most likely to return to work in such areas, and that a large proportion of nurses who work in inner cities had grown up in large cities.17 Another recently completed nursing study, in North Carolina, found that nurses cited living in the areas as a prime reason for remaining employed in rural areas and in long-term care institutions. The very high response rate--95 percent for hospitals, 75 percent for long-term care facilities, and 93 percent for health departments--makes these findings credible.18 Local access to education appears to be important in determining where newly licensed nurses will work. For example, the National League for Nursing's (NLN) 1980 survey of newly licensed nurses frog associate degree (AD), diploma, and baccalaureate programs found that more than 61 percent of AD graduates reported their residence at kc ensure as being in the same county as the location of their schools, and that 75 percent of these graduates had the same residence at licensure as the location of their employer 6 to 8 months after
162 licensure. Corresponding rates in a similar period for diploma graduates were 53 percent and 69 percent. Baccalaureate graduates were more mobile, presumably because programs were not so widely dispersed geographically. Their county residence at licensure was the same as the location of their schools for only 41 percent of the graduates. However, about 65 percent of these baccalaureate graduates reported that the location of their employer 6 to 8 months after licensure was in the county in which they had lived at the time of licensure. No county residence data are available to show geographic mobility of nurses over the longer run of their practice. However, 10 years after kc ensure, 63 percent of AD and 41 percent of baccalaureate graduate nurses reported having practiced in only one state.l9 Thus, there is some evidence to indicate that the location of the nursing education program is a determinant of where a licensed nurse chooses to work. Practical nurses also tend to live and work in the areas where they receive their nurse education. The NLN 1980 survey of newly licensed practical nurses reported that at the time of licensure, over 60 percent of new LPNs were living in the same county where their nurse education program was located. Less than 5 percent had obtained their education in a different state.20 Improvements in the accessibility of nursing programs are needed to encourage residents of underserved areas to enter nursing. Many potential students from such areas--especially those in rural c~mmunities--are unable to avail themselves of nursing education. Programs are not likely to be locally available and family responsibilities, costs, and travel distances often combine to prevent potential students from moving to communities where such programs are located. These factors, together with past experience, suggest that locating nursing education programs directly in or near medical underservice areas is a useful strategy in addressing nursing supply problems. At the federal level, the Area Health Education Center program (AHEC) has in several states mounted more narrowly focused attempts to bring nurse education to residents of underserved areas. AHEC programs encourage training for a wide range of health occupations, and also provide continuing education. The programs are offered through arrangements with existing educational and health care institutions to increase courses and to offer training experiences at hospitals and other sites in and near rural and urban underserved areas. Nursing education has received special attention in the AHEC programs in California, North Carolina, Massachusetts, and Colorado.21 In most states, community college systems have made considerable progress in developing locally accessible programs to prepare RNs and LPNs e However, where populations are not sufficiently dense to yield sufficient numbers of students, and where local educational resources are inadequate to provide an institutional base and faculty for the types of nurse education programs that prospective students may require, it is not economically or educationally feasible to provide
163 local nurse education programs. Outreach nursing education programs from state universities or from large schools of nursing offering generalist nursing education, continuing education, and even graduate education can provide an alternative to the proliferation of autonomous, inadequately staffed new schools. Outreach programs also can upgrade the education of nurses already practicing in these areas. Several programs funded under the NTA are demonstrating that nursing education programs can be offered at off-campus locations to students unable to travel or to relocate. In some instances, such as at Weber State College in Ogden, Utah, nursing faculty pay regular visits to rural countries to teach basic nursing education courses. Their students come to Ogden for short, intensive clinical experience at an affiliated community hospital. There are several variants of this type of outreach. Examples include California State University at Fresno, Montana State University, the University of Maryland (offering baccalaureate degree training to RNs with ADs or diplomas), and Wayne State University (offering master's degree preparation to RNs in remote areas of Michigan). Television,-videotapes, and other technical advances are expanding the possibilities for reaching students in remote areas or areas that lack access to schools of nursing. Today, thousands of non-nursing students are enrolled in televised courses. Several hundred colleges are members of a network working in collaboration with local television stations to offer courses.22 All these various types of programs, on and off the main campus, that offer flexibility and career mobility at various levels of nurse education appear to be sufficiently promising to merit continued support for their further development, evaluation, and dissemination of results. Conclusion There is little evidence about the success of federal efforts to relieve nursing shortages in underserved areas by financial incentives to attract nurses to move there. In many instances it appears they stay for only a limited period of service. Another approach, however--attracting residents of shortage areas into nursing--appears to have a greater potential for success. The committee notes that: o RNs and LPNs tend to practice in or near their places of origin; for rural areas that implies attracting into practice rural residents; for inner-city urban areas it implies attracting to nursing inner-city residents who are often poor and of minority racial or ethnic groups o RNs and LPN s tend to practice in the areas in which they received their nursing education · many potential candidates for nursing education are unable to relocate to gain access to nursing education · new forms of communication technology offer opportunities to develop outreach and satellite nurse education programs.
164 However, it is unrealistic to expect that access to nurse education by residents of underserved areas will occur without special targeted efforts. State and federal governments need to continue to provide special initiative grants to schools of nursing to make their educational programs available to residents of these areas through various kinds of outreach programs. New forms of communication technology that offer opportunities for outreach and satellite nurse education programs have not been sufficiently exploited. Such programs can be designed to suit the requirements and convenience of prospective students who, for reasons of family, residence, or the need to continue employment while studying, cannot readily attend existing campus educational programs. RECOMMENDATION 9 To alleviate nursing shortages in medically underserved areas, their residents need better access to all types of nursing education, including outreach and off-campus programs. The federal government should continue to cosponsor model demonstrations of programs with states, foundations, and educational institutions, and should support the dissemination of results. Education Opportunities for Minority Students In the same way that minority racial and ethnic groups frequently lack access to health care and have more illness than many others, members of these groups also have inadequate access to opportunities for nursing education.23~24 Although there are no easy solutions to the access problems of minority groups, studies by Sloan and Feldbaum suggest some strategies for improvements. Recruiting black and other minority people to join the nursing profession may help to increase the number of practical and registered nurses willing to practice in inner-city areas serving minority and underserved populations. This is consistent with the evidence that nurses tend to practice where they grew up. According to Feldbaum's studies of work location, black nurses are more inclined to work in the inner city (41.1 percent) than are their white colleagues (18.4 percent). Further, 30.8 percent of black nurses spend more than one-half of their RN working years in these locations, compared with only 8.1 percent of whites.25 Most nurses do not want to work in the inner-city environment, which is widely perceived to be not only stressful but also unsafe. Sloan reported that 72 percent of RN respondents to a survey were not willing to work in poor sections of cities, even for higher earnings--compared with 42 percent who were unwilling to work in rural
165 areas .26 However, the obverse of Sloan's findings about unwillingness to work in inner cities is that for 28 percent of nurses that was not the case. Sloan also found that black nurses are more willing to work in inner city areas than white nurses--and that baccalaureate trained nurses are less adverse to working in central cities than AD nurses.*27 The National Sample Survey of Registered Nurses, November 1980, found that minorities have high labor force participation rates, so that increasing their access to nurse education appears to be a good investment.28 The rate for whites was 76 percent, for blacks 90 percent, for Hispanics 86 percent, and for Asian and Pacific Islanders 91 percent.29 Minority nurses, both RNs and LPNs, constitute a large percentage of the nursing staffs in public general hospitals in the inner city, which serve large numbers of minority patients. Another major advantage of increasing minority representation in the nursing labor force would be that minority patients could be served by those best able to understand minority cultures and languages. The language problem is particularly acute in states with large Hispanic populations, many of whom do not speak English. Hispanic RNs are scarce. In 1974 a California study found that although Hispanics constituted over 15 percent of the population of the state they were only 1.1 percent of California RNs.30 In Arizona in 1981, Hispanics were 16.2 percent of the state's population, but only 2.5 percent of the state's RNs and 6.6 percent of its LPNs.31 The relative poverty of minority groups, closely associated with their poor health status and lack of access to care, also creates barriers to their attaining nurse education. A number of federal programs have tried to help disadvantaged individuals gain access to nursing education by offering scholarships and loans. Federal programs to facilitate nurse education for those with disadvantaged backgrounds and to help alleviate shortages in underserved areas include the Special Project Grants and Contracts Program to improve nurse training, authorized by NTA and its various amendments. Currently, two of the five stated purposes of these special grants are to (1) increase nursing education opportunities for individuals from disadvantaged backgrounds and (2) help to increase the supply or improve distribution by geographic area or by specialty group of adequately trained nursing personnel (including nursing personnel who are bilingual) needed to meet the health needs of the nation. The DHHS Division of Nursing awards grants to public and non-profit private schools of nursing and other education organizations. How the educators are to achieve the goals of the program is not specified. *Despite the tendency for minority nurses to work in these areas, a sizable proportion do not. The Feldbaum survey, which overs~mpled for black nurses, showed that 76 percent of respondents had never worked in inner-city areas.32
166 Since 1965, almost 1,000 projects have been funded under the special grants program. (Further detail is provided in Appendix 2.) The current authorization stipulates that (1) not less than 20 percent be obligated for assistance to the disadvantaged and (2) not less than 20 percent go to projects to increase the supply or improve the distribution of adequately trained nursing personnel by geographic area or by speciality group. Again, however, data are not available to show how many students have been assisted by this program.* The Nursing Student Scholarship Program, although not designed as an effort to improve access to education for those likely to serve in shortage areas, may have assisted that effort more than the programs specifically designed for that purpose. The program was first authorized in the Allied Health Professions Personnel Training Act of 1966 and continued in the Health Manpower Act of 1968, the Nurse Training Acts of 1971 and 1975, and the Nurse Training Act Amendments of 1979. As noted in Chapter III, this program is currently authorized but not funded. Nursing schools administered the program, and could award up to $2,000 per academic year to needy students. Since FY 1970, the program has awarded a total of $139.1 million to nursing schools to provide an estimated 180,502 scholarships.33 During fiscal year 1974, 79 percent of the 23,700 scholarships awarded went to students from families with incomes of less than $10,000. Of these students, 21 percent were black and 5 percent were other minorities.34 The NTA may have had a significant impact on increasing the supply of black KNs. Smith notes that "the number of blacks enrolled in KN programs began to increase dramatically after the enactment of the Nurse Training Act of 1964. . . . From 1965 to 1971, black enrollment increased by about 2,000 students each year compared to an annual increase of about 400 from 1962 to 1965.-35 Nonetheless, by 1980 only 8 percent of the employed nurse population was black and other minority.36 The committee believes that low income minority students continue to need both general and specific financial assistance to enable them to enter basic, advanced, and continuing nurse education programs, and that the net effect would be to alleviate the maldistribution of nurses. Because hospitals and other nursing employers control many of the factors that can attract or discourage nurses seeking employment, *Another program, now discontinued, was the Full Utilization of Educational Talent for the Nursing Profession. It provided incentives for special recruitment of minorities and for remedial education. Operational from 1968 to 1974, it was intended to attract students from disadvantaged backgrounds to the nursing profession, and to help alleviate shortages of fins in underserved areas. Grants were awarded to many types of organizations. The diversity of the approaches used by participating organizations made it difficult to evaluate the program. A substantial number of the targeted individuals now work in underserved areas. Most of the problems addressed by the Full Utilization Program, however, remain unsolved.
167 and because they suffer when they are unable to fill staff vacancies, it is important that they participate in future targeted programs to increase the supply of new nurses in underserved areas. When such nurse employers work closely with nurse education programs in providing clinical experiences for students, they stand to gain a cadre of graduates familiar with the operations of their institution. To the extent that they can offer some assurance that they will hire number of these graduates, they help create an attractive situation for potential students. Conclusion Certain segments of the population are particularly disadvantaged both in their access to health services and in their access to educational opportunities in nursing. Prominently included are minority groups and new immigrant residents of rural and inner-city areas. Strategies to develop manpower to provide more adequate nursing services under these conditions require targeted approaches. Special efforts must be made to reduce financial barriers to nursing education for residents of such areas, to offer reasonable opportunities for future employment in these areas, and to accustom students to the situations they are likely to encounter in providing nursing services in these areas. In addition to general educational outreach efforts, nurse educators and health care employers can improve access to nursing education in underserved areas by cooperating to develop programs to ensure that students are recruited from minority groups, that they will be given special consideration for employment, and that they gain clinical experience in shortage area facilities, e.g., rural and inner-city hospitals, nursing homes, and public health clinics. Consortia of educational programs and health care facilities may be successful in recruiting such students, attracted by improved prospects of future employment. The facilities themselves may benefit by improved prospects of a continuing supply of newly graduated nurses who live in their area and are already familiar with their operation. Patients will benefit because these nurses are more likely to speak their language and to be familiar with their health needs. The federal government should, therefore, encourage consortia of nurse educators and nurse employers by offering institutional and student support for educational programs targeted, though not limited, to members of minority and ethnic groups. Opportunities for nurse education at all levels could be offered. The programs should be designed to ensure that the students, the prospective employers, and the educational institutions all have incentives for making the program successful in recruiting and retaining students most likely to practice in underserved settings, whether urban or rurale After initial funding, the continued support of the programs could be contingent on the success of institutions in reaching shortage areas and encouraging their graduates to serve in inner-city or rural areas. The committee believes that performance
168 incentives to nurse education programs are more likely to succeed than the traditional loan forgiveness or special grant programs of the past, largely targeted directly to the student. Additionally, most committee members believe that the programs should attach service commitment obligations to student aid.* States should, of course, also play a major role in sponsoring or cosponsoring nursing education targeted to increasing the supply of nurses in underserved areas. Federal initiatives should be offered on a competitive basis and be coordinated with state higher education agencies, health planning authorities, and other organizations that have the explicit responsibility for planning the distribution of nursing education resources to meet the state's manpower needs. They can make major contributions to the screening and evaluation of proposals as well as ongoing results. RE 0 MMENDATION 10 To meet the nursing needs of specific population groups in medically underserved areas and to encourage better minority representation at all levels of nursing education, the federal government should institute a competitive program for state and private institutions that offers institutional and student support under the following principles: · Programs must be developed in close collaboration with, and include commitments from, providers of health services in shortage areas. · Scholarships and loans contingent on commitments to work in shortage areas should be targeted, though not limited, to members of minority and ethnic groups to the extent that they are likely to meet the needs of underserved populations, including non-English-speaking groups. Adequate Revenues for Inner-City Hospitals As a result of severe resource constraints, some very large inner-city hospitals, particularly tax-supported institutions, have difficulty recruiting and retaining nurses. Constricted revenues limit the abilities of these public hospitals to offer competitive salary structures and to improve general patient services and working conditions. Some factors, such as the location of many public hospitals in deteriorating and unsafe areas, cannot be changed by *Some committee members question the effectiveness of service commitment obligations and their equity.
169 recommendations within the purview of this studye However, because these institutions serve as the cornerstone of care for the urban underserved, the committee devoted special attention to their problems. While some of the burden of caring for uninsured inner-city populations clearly falls upon the private sector voluntary hospitals, the major part falls on public facilities. For example, in 1980, the Greater Cleveland Hospital Association reported that in its area, 5 out of 51 hospitals provided 90 percent of the unreimbursed care. Further, the association noted that 80 percent of all unreimbursed in care in Cleveland was for outpatient, clinic, and emergency services.37 In a 1977 report on public general hospitals it was found that they offered important services frequently not provided by other hospitals. On the basis of 1976 data, it showed that in the nation's 100 largest cities, public hospitals represented slightly less than 10 percent of community hospital facilities but provided 45 percent of all ambulatory care visits (i.e., hospital clinic visits for primary care and special diagnostic or therapeutic services). In these cities, the public hospitals also provided more than one out of every four hospital emergency room visits in the community. One-half of all public hospitals in these 100 cities provided neonatal intensive care, one-quarter provided alchohol detoxification services, and one-fifth provided emergency psychiatric care.38 These hospitals are also often regional referral centers and teaching hospitals. Such factors, combined with the severity of the conditions of the patients they serve, result in high costs--often higher than other hospitals of comparable size in their regions. Federal and state governments have a substantial responsibility for the quality of care in inner-city public and voluntary hospitals, most of which serve not only the unsponsored poor, but also large numbers of Medicare and Medicaid patients for whom payment of necessary expenditures often cannot be fully recovered because of prescribed limitations. Many of the problems that threaten the financial viability of these institutions are created by decisions made by governments about reimbursement levels and scope of services covered by public programs, as well as by other types of federal decisions or nondecisions, such as those related to illegal immigration.39 Faced by a worsening economy, upward pressures on public sector spending, and a powerful public mandate to decrease taxes and government expenditures' spending restrictions are imposed on programs that serve the nation's poor citizens--particularly Medicaid, the second largest public sector program.40 Hospitals serving minority and Medicaid patients in inner cities are more financially threatened than are other acute care hospitals. The closing of many state mental hospitals and the impending closure of neighborhood health centers in various cities compound the problem. When such closings occur, displaced patients rely ever more heavily on the larger public and voluntary hospitals. Also, as voluntary hospitals fight to retain a mix of patients by payer status, and usually by race as well, they become less able or willing to provide care to increasing numbers of nonpaying patients. So-called
170 "dumping" or transfer of nonpaying patients from private to public hospitals is not a new phenomenon, but it appears to be increasing. Although no national data are available, accounts of individual hospital's experiences have been reported by the media. Cook County Hospital in Chicago, for example, recently experienced an increase of transfers out of private hospitals, from about 125 to almost 400 per month.41 Nursing is a particularly serious problem for inner-city hospitals. A 1980 survey of mayors, city council presidents, and city managers of cities with public hospitals reported that next to the high costs of such hospitals the shortage of nurses was the most important health problem they faced.42 The 12 hospitals and 4 long-term care facilities composing the New York City Health and Hospitals Corporation (HHC) offer a useful illustration. One-third of New York City municipal hospitals have less than 70 percent of the required number of registered and practical nurses. Almost none of the HHC hospitals have sufficient RNs to meet the corporation's own standard for RNs, three-quarters do not have the required number of practical nurses, and over one-half are deficient in nurses' aides.43 Conclusion Many inner-city public hospitals (county-, city-, or state-owned), as well as some inner-city voluntary hospitals, bear the major burden of serving the uninsured poor. They generally also serve disproportionately large numbers of Medicaid and Medicare patients. Many of these hospitals are teaching hospitals, affiliated with academic health centers, and serve as regional referral centers for very sick patients who require extraordinary inpatient medical and nursing attention. They also provide, on an outpatient basis, a heavy volume of episodic primary care and emergency room services to otherwise medically underserved persons. Failure of Medicaid and Medicare programs to cover large segments of the sick poor, or to allow payment sufficient for these hospitals to recover their necessary expenses of the poor and elderly they do cover, threatens the existence of this essential part of the nation's health services. It stands in the way of improvements in patient services, physical plant, and general working conditions. It contributes to the traditional difficulties that inner-city public hospitals encounter in recruiting and retaining nurses. In short, Medicaid and Medicare coverage and payment levels are among the reasons that inner-city hospitals have nursing shortages. The service missions of some hospitals may result in justifiably higher expenses and lower revenues than those in institutions classified as comparable in scope, size, or service. Differential payments can be established to take these factors into account. One approach used in some cases of prospective payment or rate making involves pooled funds established under state auspices (with federal Medicare waivers) in which all payers are required to share equitably in hospitals' unrecovered revenues. Although differential payments
171 cannot assure an adequate nursing supply, they may be necessary to maintain institutional solvency. As new methods of payment are developed for public and other third-party payors during the coming years, it also will be important to allow for the costs of service and management improvements to redress past deficiencies. Payment systems can be designed to allow for improvements in the working conditions and competitive salary structures (see Chapter VII), and thus promote attainment of more adequate nurse staffing levels. RECOMMENDATION 11 Differential allowances in payment should take into account the special burdens on inner-city hospitals that demonstrate legitimate difficulties in financing services because of disproportionate numbers of uninsured or Medicaid and Medicare patients. Federal, state, and local governments and third-party payers should pay their fair shares of amounts necessary to prevent insolvency and to support acceptable levels of service, including nursing care. Nursing Education for Care of the Elderly After examining general problems of underservice and special problems of the inner cities, we turn to the largest single population group that suffers from a lack of adequate nursing services--the elderly. Currently, there are 23 million people aged 65 and over; 18 years from now, in the year 2000, there will be nearly 32 million. The most vulnerable part of this population is growing at a particularly rapid rate. Since 1950 the number of people aged 75 years and over has doubled. This group uses hospital, nursing home and home care services at rates double or triple those of the population as a whole.44 Only about 5 percent of the elderly are in nursing homes at any one time, although one in five will be there at some time in their lives.45 Thus the vast majority of the elderly live at home--alone or with their families--or in residential housing for the elderly. When these people receive nursing care it is in ambulatory clinics, physician's offices, hospitals, and sometimes at home. Many experts on the needs of the elderly believe that their health care is not properly adapted to their special needs. There is a tendency for nurses and physicians alike to inappropriately dismiss treatable symptoms, too often automatically regarding them as part of an inevitable, irreversible process of aging. The result of such attitudes is unnecessary disability and institutionalization. Many
172 elderly could remain at home, or in a less restrictive environment, if a greater emphasis were placed on their special needs, which include attention to preventive care and the active management of both acute and chronic conditions. The committees' attempts to understand some of the reasons for less than optimal care for the elderly and unnecessary institutionalization revealed that preparation to serve the elderly is rarely emphasized in the education of the health service professions. Most basic nurse education programs fail to provide either theoretical or clinical preparation in geriatrics or long-term care.46 Even at advanced educational levels such preparation is scarce. In 1977 only eight schools of nursing had graduate programs in gerontology.47 By 1980 only 20 or so schools offered such education.48 Reif and Estes suggest that the slow growth of gerontology education may be the result of the limited availability of funds to maintain and develop such programs.49 This lack of focus on the elderly during the years of educational preparation may be one reason licensed nurses are not attracted to geriatric care. For example, as noted in Chapter I, only about 8 percent of all employed RNs worked in nursing homes in 1980. The committee believes that if nursing education were to provide special preparation in all of the many aspects of geriatric care, licensed nurses would gain an understanding of the special needs, challenges and rewards of caring for the elderly, and thus become more attracted to employment in all the settings where those people receive care--at home, in clinics, in hospitals, and in long-te`~. care facilities. In recognition of these problems the Robert Wood Johnson Foundation joined with the American Academy of Nursing in sponsoring the Teaching Nursing Home Program. In 1982, 11 academic schools of nursing received 2-year grants to develop affiliations with nursing homes. The nursing schools are to assume overall responsibility for clinical care of the residents. Faculty will teach students and staff, conduct research, and develop outreach services; nursing students will have clinical experiences in the nursing homes. Conclusion The most rapidly growing segment of the population--the elderly--is a group particularly in need of the many services that nurses can provide. Among the elderly, those who are age 75 and older are the most prone to multiple disabilities and chronic diseases. They use hospital, nursing home, and home care services at rates double or triple those of the population as a whole. Elderly patients are found in almost all health care settings. Their needs range from preventive, acute care, and rehabilitation services that help them maintain maximum independent functioning as long as possible, to care that eases the course of terminal illness and its impact on both patients and family. Nursing students need realistic preparation to dispel common misperceptions about the problems of the elderly. Neither basic nor advanced nursing education programs yet focus
173 suff iciently on academic preparation and clinical experiences in geriatrics . RE COMMENDATION 12 The rapidly growing elderly populat ion requires many kinds of nursing services for preventive, acute, and long-tenn care. To augment the supply of new nurses interested in caring for the elderly, nursing education programs should provide more formal instruction and clinical experiences in geriatric nursing. Federal support of such efforts is needed, as well as funding from states and private sources. Upgrading Existing Staff in Nursing Homes Although geriatric care in all settings requires special skills and knowledge, it i s part icularly important in nursing home s and other institutions caring for the elderly. The multiple health problems of the institutionalized elderly present extraordinary challenges for those entrusted with their nursing care. The average nursing home patient is 78 years of age, has multiple chronic conditions, and is confined to chair or bed. About one-third are severely disoriented and 25 percent have chronic brain syndrome.50 In 1977, skilled nursing fac ilities reported that they provided intensive care to almost one-half their patients in the week prior to the National Nursing Home Survey. Yet, the vast majority of nursing care in nursing homes is given by personnel prepared at less than the RN level. In 1977, the last date for which comprehensive information is available, only 22 percent of nursing homes had an RN on duty around the clock, 71 percent of nursing personnel in skilled nursing fac ilities were aide s, 14 percent were licensed practical nurses, and 15 percent were RNs .51 Aides, generally minimally prepared for their responsibilities, provide six times as much care in nursing homes as do registered nurses, and f ive times as much care as do licensed practical nurses. They may often perform complex nursing t asks . No national study has explored the actual tasks RNs, LPNs ~ and aides carry out in nursing homes. However, a study in Utah elicited the opinions of a panel of nurse educators to determine which of 78 nursing tasks could be safely performed by RNs, by LPNs, and by aides. The panel judged that RNs could perform all 78 tasks, LPNs 72, alla aides 51. Survey questionnaires were administered to an RN, an LPN, and an aide in each of 7 9 nurs ing homes with reputat ions f or good nursing care to learn which of these spec if fed nursing tasks each category of personnel reported that they in fact actually carried out. The KNs reported that they performed all 78 tasks. So did the
174 LPNs, including six tasks the panel had judged them unqualified to perform. For example, 33 percent of the LPNs reported that they regulated intravenous flow, 29 percent regulated blood transfusion flow, 26 percent inserted nasogastric tubes, 21 percent prepared and gave intravenous medications; 5 percent started intravenous fluids, and 3 percent started blood transfusions. In this same study, nurses' aides reported that they perfo`~.~ed a far greater number of tasks than those for which the panel had deemed them qualified--74, instead of the 51 specified. For example, 33 percent of the aides reported that they removed fecal impactions, 30 percent counted apical pulses; 25 percent suctioned patients' noses; 11 percent suctioned patients' throats, and 4 percent prepared and gave oral medications.52 There is no reason to believe that the nursing services provided in Utah's nursing homes differ from those in other states. For the nation as a whole, various estimates have been made on the basis of professional judgments that indicate serious deficiencies of nurses in long-term care. As described in Chapter II, judgment-of-need model estimates indicate that nursing homes are grossly understaffed. An estimate published by the Administration on Aging indicates that, by 1985, 101,000 FTE KNs would be needed in nursing homes, a substantial increase over the 77,000 FTE RNs employed in nursing homes in 1980.53,54 The previous recommendation, which suggested a way of dealing with this problem for future generations of nurses, can ameliorate the problem only in the long run. For the short run, upgrading the skills of current nursing home personnel appears to be urgently needed. One example of a promising program to reach RNs in nursing homes is a project funded by the W.K. Kellogg Foundation in 1981. It provides an interesting example of collaboration between educational institutions and nursing homes. The universities of Arizona, California at San Francisco, Washington, and Colorado have received grants to recruit registered nurses already working in nursing homes. These nurses will become qualified as geriatric nurse practitioners after spending 3 months on campus, followed by 8 months of clinical experience on the job under a physician or geriatric nurse practitioner preceptor. In-service training or continuing education in geriatric nursing for LPNs, aides, and orderlies has been encouraged to some degree under the NTA Special Grants program. Not less than 10 percent of the $6.2 million FY 1982 funds for special grants was to be spent for projects to upgrade the skills of vocational or practical nurses, nursing assistants, or other paraprofessional nursing personnel. Conclusion The many personnel now employed in long-term care institutions generally have not had adequate preparation in caring for the elderly. The quality of care could be improved by upgrading their education. The magnitude of the problem indicates that financing, program, and faculty resources are insufficient and must be developed
175 in many localities. To do this requires federal encouragement to stimulate further the cooperation of those involved--nursing care providers, educational institutions and other private organizations. RECOMMENDATION 13 Nursing service staffs in nursing homes certified as "skilled nursing facilities" and in other institutions and programs providing care to the elderly often lack necessary knowledge and skills to meet the clinical challenges presented by these patients. Such facilities, in collaboration with nursing education programs and other private and public organizations, should develop and support programs to upgrade the knowledge and skills of the aides, LPNs, and RNs who work with elderly patients. States should assist vocational and higher education programs to respond to these needs. Federal support of such programs should be maintained. Adequate Payment for Long-Term Care Registered nurses are not attracted to work in nursing homes. Working conditions are poor, salaries are low, and fringe benefits rarely are offered. Root causes generally are agreed to be current lack of insurance coverage for long-term care, and policies governing Medicaid payment. Somers notes that Medicare coverage specifically excludes both preventive services and all but a modicum of long-term care. "The Medicare message to the average patient is clear. 'Get well fast or get lost."'55 Private insurance also generally fails to cover long-term care. Even major medical insurance usually excludes care in nursing homes and often limits home care to full-time private duty nursing.56 Medicaid covers long-term care, but only for the elderly who have completely exhausted their financial resources. Together, the state medicaid programs provide more than 50 percent of nursing home revenues. Current federal Medicaid standards, embodied in DHHS conditions of participation, require the presence of an RN only for the day shift in skilled nursing facilities (SNFs). (Intermediate care facilities (ICFs) can use an RN or LPN to supervise the day shift.) The problems resulting from inadequate Medicaid payment for nursing home care are generally recognized. Testimony presented to the Select Committee on Aging of the House of Representatives avers that federal nurse staffing standards in nursing homes, while they are intended to establish only a minimum requirement, have been interpreted by Medicaid programs in same states to represent a maximum limit on licensed nurse hours. Mandatory strengthening of the
176 staffing standards therefore appears to be required to correct this situation, and to avoid penalizing through the payment system those homes that choose to provide more generous services to their patients. More than two-thirds of the nonprofit nursing homes represented by the American Association of Homes for the Aging recommended strengthening the standard to 24-hour coverage by licensed nurses.57 However, under the current Medicaid reimbursement system, facilities appear to be faced with a choice of paying high salaries to a few nurses or paying low wages to a greater number of unskilled aides.58 Full-time RNs per 100 nursing home beds range from '.2 in Texas to 9.6 in Alaska.59 As noted in Chapter I, RNs have very little time to spend with nursing home patients--12.5 minutes of KN patient care per day in SNFs, were one to assume that RN time was entirely devoted to bedside care. In fact, most of the RN's time in nursing homes is said to be devoted to administrative and supervisory functions. Institutional care-is, of course, only one component of the elderly's need for nursing services. At any one time, 95 percent of the population 65 years of age or over maintain their own households or live with their families. Many of these people, especially at the higher end of age spectrum, have disabling conditions requiring a certain amount of nursing care. Many elderly patients are in nursing homes because they lack access to home nursing and other services that would enable them to remain at home. Medicare does not reimburse for nursing services to the homebound unless they are in need of defined "skilled nursing services." Medicaid pays for home health services to the destitute elderly, depending on the scope of each state program's benefit policies. However, the amount of spending for these purposes has been very limited. Up to now, less than 1 percent of Medicaid expenditures have been used to fund long-term care outside of institutions.60 Recent changes in the law permit state Medicaid programs to obtain waivers enabling them to offer a much wider array of home and community-based services to certain categories of people living at home. These changes, made in the Omnibus Reconciliation Act of 1981 (Public Law 97-35), have stimulated 34 states to apply for waivers as of December 1982. The Health Care Financing Administration had approved waivers in 24 states as of that date.61 The movement to strengthen home care services for the elderly received a special impetus from the 1981 White House Conference on Aging. Among some 660 recommendations, those for expanding home health care and other home services received the second highest net score of favorable votes.62 In 1979 there were 3,000 Medicare-approved home health agencies employing community health nurses.63 The number of nurses working in hone care agencies increased from 6, 600 in 1972 to about 20,000 in 1979. Such agenc ies primarily, but by no means exclusively, have older people as clients. The new Medicaid waivers are likely to stimulate this sector of demand, provided that sufficient funds are made available for the agencies to offer competitive salaries for RN and LPH home care nurses. One result has already been to strengthen
177 nurse practitioner programs. (Nurse practitioners will be discussed in the section to follow.) It is evident that changes in the payment levels of federal programs could cause a major increase in demand for both home care and long-term care nurses. It is also evident that an increase in both the amount of licensed nursing care in SNFs and ICFs, and an increase in home nursing services, would immeasurably benefit the elderly population. Conclusion Private insurance rarely offers benefits to cover the costs of health services needed by elderly patients at home or in nursing homes for long-term illnesses and disabilities. Medicare benefits are almost entirely limited to acute care services. Medicaid provides extensive benefits for the destitute elderly in nursing homes, but, in most states, restrictive payments discourage the employment of more than minimal numbers of skilled nursing personnel. Among the nursing homes certified for payment under the Medicaid and Medicare programs, almost two-thirds of the patients are in homes certified either as a skilled nursing facility (SNF) only, or as some combination of SNF and intermediate care facility (ICF). Patients in such institutions are usually severely disabled or ill, and are frequently disoriented. They often require expert nursing services. Aides constitute by far the largest proportion of nursing service personnel in SNFs and combined SNF/ICFs. Licensed nurses (RNs and LPNs) are responsible for their supervision, as well as for the direct care of patients, for recordkeeping, and for decisions about emergency situations that usually must be made with no physician in immediate attendance. Federal certification requirements call for only minimal RN staffing; e.g. in SNFs a full-time RN on the day shift 7 days per week. Facilities have few incentives to exceed minimal staffing standards. Given the magnitude of the nursing requirements of SNF patients, the committee believes that regulations and payment systems should be modified to advance toward the goal of 24-hour RN coverage. RECOMMENDATION 14 The federal government (and the states, where applicable) should restructure Medicare and Medicaid payments so as to encourage and support the delivery of long-term care nursing services provided to patients at home and in institutions. For skilled nursing facilities, such payment policies should encourage the continuing education of present staffs and the recruitment of more licensed nurses (RNs and LPNs), and should permit movement toward a goal of 24-hour RN coverage.
178 Lowering Barriers to Expanded Nurse Practice The term nurse practitioner (NP) refers to nurses whose education extends beyond the basic requirements for licensure as a registered nurse and prepares them for expanded functions in relation to diagnostic and treatment needs of patients, as well as in primary prevention measures. Most are prepared in certificate programs, but an increasing number are prepared in master's degree programs (Appendix 4~. This section of the report highlights the potential of NPs to provide services to underserved populations and especially to care for elderly people. The National Sample Survey of Registered Nurses, November 1980, reported that there were more than 16,700 nurse practitioners and nurse midwives. As is noted in other chapters, NPs were employed in numerous health care settings. In that year, 5,600 worked in hospitals, 4,000 in physicians' offices (including HMOs), and approximately the same number worked in public health or community health. Together, NPs constituted about 1.3 percent of the RNs employed in nursing. Preliminary data from the Division of Nursing and American College of Nurse Midwives show that as of 1982 the overall number had grown to more than 20,000 nurse practitioners, of whom 2,598 were nurse midwives. Nurse practitioner programs currently supported under NTA place emphasis on training to meet the particular problems of geriatric and nursing home patients, as well as to provide primary care in homes, ambulatory clinics, long-term care institutions, and other health care institutions. NP traineeship recipients must agree to practice in a health manpower shortage area for a period equal to 1 month for each month of assistance, or to repay the amount of their assistance. In fiscal year 1980 the federal government spent over $2 million on geriatric nurse practitioner training programs.64 Nurse practitioners have demonstrated willingness to provide needed services in inner cities and rural communities. In 1977, 23 percent of NPs were employed in inner city settings and another 22 percent in rural areas.65 Thus, 45 percent of practicing NPs were located in the geographic areas of greatest need. (Some nurse practitioner programs specifically prepare NPs for practice in rural or other underserved areas, notably those at the universities of California, Minnesota, and North Carolina. The Graduate Medical Education National Advisory Committee (GMENAC) cites data from a 1976-1977 survey indicating that 10 percent of nurse midwives work in communities with populations under 10,000.67 Nurse practitioners and nurse midwives, working under established protocols, have proved effective in the delivery of primary care in some settings. Some studies have found that the use of NPs in organized health care settings resulted in productivity gains and cost reductions. For example, Holmes observed that a physician/nurse practitioner team was more productive than a physician working alone.68 Such augmentation of productivity could help make physician practices in some underserved areas financially viable. The 1978 Institute of Medicine study on manpower policy for primary care endorsed the use of NPs. That report stated:
179 . . . even with the prod ected increase in the supply of physic fans, physic fan assistants and nurse practitioners have an important role to play in the de livery of primary care. Their role in those rural communities unable to support a physician is of part icular importance. In the opinion of the conuT~ittee, rural communities with populations of 4, 000 or less may be adequately and economically served by a physician assistant or nurse practitioner with physician backup. Even in more populated rural communities, they can augment the care provided by the physician so that the patient can obtain needed primary care on a 24-hour basis. In addit ion, new health pract itioners can improve access to primary care in urban settings, especially in hospitals, nursing homes, and as part of a team in a group practice. Moreover, the committee views these providers as enhancing the delivery of primary care by educating patients to lead more healthful lives. . . By concentrat ing on c ommunic at ion with pat lent s, ~ they ~ might help pat tents to adhere more closely to prescribed reg imens and t o a s sure inc rea sed re span s i hi 1 ity f o r their own health. . . 69 The use of NPs in the care of the elderly has potential for improving the health states of this group. A study reports that an adult health nurse practitioner/physician team delivering primary health care to the elderly reduced hospital days and the use of diagnostic and therapeutic procedures.70 A Rand study predicts a need for 12,000 to 20,000 geriatric nurse practitioners by the year 2010, depending on the amount of responsibility delegated by physicians. 71 The study indicates that geriatric nurse practitioners could play a signif ic ant role in caring for elderly people. Much larger numbers of geriatric NPs have been predicted to be needed by that date in estimates being submitted to the National Institute on Aging.72 Two major factors control the extent to which NPs can furnish primary care to underserved populations: (1) NP practice is regulated by state practice acts that define the scope of nursing practice, (2) payment for NP services by federal programs determines the economic feasibility of using NPs. In recent years, many states have amended physician and nurse practice acts to allow new health practitioners to perform some medical procedures under various conditions.* Most nurse prac t ic e ac t s re qu ire phy s ic fan sup ervi s ion of NP ac t iv it ie s; *See Habibi, M. Legal issues influencing nursing practice. Background paper of the Study of Nursing and Nursing Education. Available from Publication-on-Demand Program, National Academy Press, Washington, D. C., 1983.
180 therefore the presence of NPs in underserved areas depends not only on their own interest, but on their ability to make arrangements with hospitals or physicians . Nurse midwives, many of whom practice in rural and urban underserved areas, also must make such arrangements. In recent years, state laws have become increasingly supportive of midwifery practice. The number of states with statutes or regulations allowing nurse midwives to practice is reported to have increased frog 16 in 1977 to 32 in 1980.73 The level at which nurse practitioners can be used is directly related to the licensing provisions in any given state. State legislators, in considering changes in nurse practice acts and related legislation, usually confer with representatives of the medical profession as well as with nursing groups. There are differences of viewpoint as to practice proposals. For example, physician supervision of NPs may be defined as requiring the presence of the physician at the site of practice. Same critics of organized medicine have observed that economic concerns may influence the attitudes and actions of some medical practitioners, especially in the face of the increasing supply of physicians. However, there also are genuine concerns about the quality of care that might be given by NPs in the absence of a physician. The committee did not attempt to resolve these questions because its recommendation deals only with nurse practitioners functioning in organized settings and in joint physician-nurse practices. Medicaid and Medicare payment policies affect the ability of ambulatory clinics, physicians, and health care institutions to employ NPs. The Medicaid programs in approximately one-half the states specifically provide some type of reimbursement for physician extender services such as those by nurse practitioners or physician assistants.74 Federal reimbursement policies in the Medicare and Medicaid programs allow institutions to include physician extender compensation in their calculation of reasonable costs. But federal payments for primary care services, provided by physician extenders outside of institutions, have been restricted. In most cases, services traditionally performed by physicians are not reimbursable under federal programs when provided by physician extenders.75 The Rural Health Clinic Services Act of 1977 (Public Law 95-210) eliminated such restrictions in the Medicare and Medicaid programs for physician extenders practicing in certified rural health clinics in designated underserved areas. The Act provides payment for physician extender services even if not directly supervised by a physician. However, where state practice laws require on-site physician supervision, their provisions often appear to govern. Studies confirm that NPs are willing to provide primary care in parts of rural and inner-city underserved areas where physicians at present do not practice. There is, however, considerable debate on the long-term prospects for using substantial numbers of such practitioners in ambulatory care in view of the increasing supply primary care physicians. Physicians are increasingly moving into small communities. It is not possible now to project how many nurse practitioners will be needed in the future and where they will of
181 practice. GMENAC estimated that the supply of NPs will rise to 39,000 by 1990.76 Conclusion Continued federal funding is needed for nurse practitioner training. It should, however, be weighted toward supporting the training of RNs most likely to practice in underserved areas, in nursing homes, and in caring for the elderly in other settings. funding can profitably be directed at training RNs already living in underserved areas or already working in long-term care settings, since they are most likely to continue practicing there. The legitimate role for nurse practitioners is hampered in many instances by state laws and third-party reimbursement practices. Their services in organized settings and in joint physician-nurse practices should be covered by Medicaid, Medicare, and third-party payers. This does not, however, imply an intention to restrict payment for services that states already authorize. Approximately half the states now provide same Medicaid reimbursement for physician extender services provided by NPs or physician assistants. Since 1977 the Rural Health Clinic Services Act has waived payment restrictions in the Medicare and Medicaid programs under defined safeguards where such physician extenders practice in certified rural health clinics located in designated underserved areas. There are examples of the use of NPs and nurse midwives in organized health care settings contributing to productivity gains and cost reductions. Even with the anticipated future increases in physician supply, it is likely that NPs will be needed, especially to serve hard-to-reach populations, to facilitate new organizational arrangements for providing health care in cost effective ways, and augment the quality and amount of care provided to the elderly in their own homes and in nursing homes. RECOMMENDATION 15 to There is a need for the services of nurse practitioners, especially in medically underserved areas and in programs caring for the elderly. Federal support should be continued for their educational preparation. State laws that inhibit nurse practitioners and nurse midwives in the use of their special competencies should be modified. Medicare, Medicaid, and other public and private payment systems should pay for the services of these practitioners in organized settings of care, such as long-term care facilities, free-standing health centers and clinics, and health maintenance organizations, and in joint pl~ys~ciar~-nurse practices. (Where state payment practices are broader, this recommendation is not intended to be restrictively
182 Financing Recommended Actions The committee has presented recommendations in this chapter that would involve redirection and reauthorization of a number of NTA programs designed to alleviate chronic nursing shortages for various geographic areas, population groups, and institutions. These approaches can be grouped as (1) manpower distribution policies to facilitate the education and employment of individuals most likely to work in rural and inner-city areas, including nurse practitioners; (2) payment changes to enable skilled nursing facilities and inner city hospitals to support acceptable levels of service, including more adequate nursing care in such institutions, and to facilitate the employment of nurse practitioners to care for rural and elderly patients; and (3) policies to improve nursing care for the elderly through incentives to educational institutions and health care providers, first by enhancing the geriatric component of educational programs so that new graduates will be more likely to want to work with the elderly and be more skilled in doing so, and second by improving the skills and knowledge of all levels of nursing personnel who already care for elderly people in long-term care institutions. Manpower Distribution Policies The principal recommendation in this category suggests incentives to states, educational institutions, and health care providers to develop consortia and model demonstrations that address specific shortage problems in medically underserved areas. A key strategy is to bring educational opportunities to potential students who already live in those areas. The committee is not suggesting a large-scale program of diffuse student and institutional support as occurred in the past, but rather carefully targeted aid for local initiatives that will attract added local resources. Past federal expenditures to address nursing maldistribution problems were included among the Nurse Training Act authorizations for loans and scholarships for disadvantaged people, special project grants, and training for nurse practitioners. These loan appropriations peaked at $33.5 million in 1976, at which time $12 million was also available in scholarships. By 1982, the loan program had been reduced to $7.5 million and the scholarship program discontinued. However, many nursing schools still have large cash balances in the loan program, totaling $54 million nationwide, and substantial amounts are owed in delinquent loan repayments, some of which may be repaid.77 These funds presumably could be retargeted to support a substantial number of loans through 1986 (the end of the period during which the money may be reloaned). In addition, a relatively small amount of new funds for loans targeted to educational activities in underserved areas would speed improved geographical distribution. Federal capitation (no longer authorized) and special project funds (authorized in 1981 at about $12 million), which had many purposes,
183 have also been used to address problems of underservice. Same of these funds have been used to develop innovative outreach and collaborative programs, recruit disadvantaged students, and improve the distribution of nurses. In sum, many of the committee's objectives and strategies have been stated among the objectives of past federal efforts, but the impact has at~times been lost because of diffuse funding arrangements. Furthermore, inadequate data and poor institutional records have frustrated the evaluation of their impact on the intended problem areas. In view of federal budget constraints, the committee believes that levels of funding as high as in the past may not be feasible or even necessary. Rather, smaller but more carefully targeted expenditures would be effective to develop concentrated approaches to the problems of recruiting minority and other students who are likely to work in underserved settings. The recommended activities to stimulate consortia for underserved areas could be supported by appropriations for special project grants and contracts at about the 1981 level. In addition to the need for generalist RNs to care for underserved populations, the committee sees a need for nurse practitioners to care for elderly clients and provide primary care in underserved areas. Specific federal support for nurse practitioner education programs has been authorized under the NTA since 1976. Funding was at the $13 million level between 1978 and 1981. Although in recent years special consideration has been given to institutions that prepare nurse practitioners to deal with the special problems of geriatric patients at home and in nursing homes and to serve in health manpower shortage areas, many NPs subsequently find employment elsewhere. NP students have also been assisted by Traineeships for Advanced Training of Professional Nurses. This program supports a whole range of advanced nurse education. It was also funded annually at about $13 million between 1979 and 1981. The committee endorses continued funding at present levels for the education of nurse practitioners, but with stronger program incentives for them to work in underserved areas and in the care of the elderly. Payment Changes Manpower policies address only part of the underservice problem Perhaps the most important obstacle to adequate nursing care for residents of skilled nursing facilities and patients in inner-city hospitals is in the lack of financial resources in these institutions. The committee has placed no explict price tag on these recommendations because they are part and parcel of major program reforms required in Medicare and Medicaid payment systems to assure that cost constraints are balanced by broad equity considerations. Any added costs are not fairly attributable to nursing, although nursing improvements are intended as one of the results of more adequate payment for total care.
184 Improving Nursing Care for the Elderly Training of all levels of nursing personnel, including aides, LPNs, and RNs, has failed to pay sufficient attention to the special problems of caring for the elderly. We have recommended that educational institutions in collaboration with providers strengthen their curricula to remedy this situation by encouraging more nurses to pursue careers in geriatric nursing. We also see a need for continuing education to upgrade the skills and knowledge of those currently employed in long-term care. Providers and educational institutions should take the lead and primarily bear the costs of developing both these types of educational programs, with additional financing from state agencies and foundations. The federal contribution to such improvement and to efforts to upgrade the skills of LPNs, aides (nursing assistants), and other nursing personnel has been expressed in the past primarily through the NTA special projects grant program. In the Omnibus Reconciliation Act of 1982, Congress stipulated that not less than 10 percent of special project funds be devoted to upgrading the skills of vocational or practical nurses, nursing assistants, or other paraprofessional nursing personnel. At the same time, however, Congress eliminated from the authority support for curriculum improvements and short-tenm in-service training for aides and orderlies. The provisions that remain could nevertheless allow for greater federal participation to implement the committee's reco~u~ended actions to improve geriatric nursing care. The committee believes that if special project grants were funded at a level equivalent to the average of 1980-1982 appropriations ($11 million), the federal share of the committee's recommendations could be accommodated. REFERENCES AND NOTES 1. 4. Davis, K. Primary care for the medically underserved: Public and private financing. Paper presented at the American Health Planning Association and National Association of Community Health Centers, Inc., Symposium on Changing Roles in Serving the Underserved, Leesburg, Va., October 1981. 2. Blendon, R.J. Untitled testimony presented to the Subcommittee on Health and the Environment of the House Committee on Interstate and Foreign Commerce, March 4, 1981. 3. Murrin, K. Laying the groundwork: Issues facing rural primary care. In G. Bisbee (Ed.), Management of rural primary care--Concepts and cases. Chicago, Ill.: The Hospital Research and Educational Trust, 1982. Mullner, R. American Hospital Association. Personal communication, July 2, 1981. Center for Health Services Research and Development. Physician distribution and medical licensure in the United States. Chicago, Ill.: American Medical Association, 1979, unpublished data.
185 6. Roth, A., and Patchin, N. Geographic distribution of nurses in relation to perceived recruiting difficulties and economic conditions. In 11. Millman (Ed.), Nursing personnel and the changing health care system. Cambridge, Mass.: Ballinger Publishing Co., 1978. Rural Health Care: Hearing before the Subcan. on Health of the _ Comm. on Finance, 97th Cong., 1st Sess. 55 1981 statement of William Leary, Montana Hospital Association) Rural Health Care: Hearings before the Subcom. on Health of the - Comm. on Finance, 97th Cong., 1st Sess. 40(1981) (statement of Jo Anne Dodd, Montana Nurses' Association) 9. Rural Health Care: Hearing before the Subcomm. on Health of the Corr=. on Finance, 97th Cong., 1st Sess. Op. cit., p. 62. 10. Secretary of Health and Human Services. Health' United States, 1981 (DHHS Publication No. PHS-82-1232~. Washington, D.C.: U.S. Government Printing Office, 1982, p. 90. 11. Ibid., p. 93. 12. Davis, K., and Schoen, C. Health and the war on poverty: A ten~ear appraisal. Washington, D.C.: The Brookings Institution, 1978. 13. Blendon, R.J. Op. cit., p. 7. 14. Secretary of Health and Human Services. Health. United States ~ 1 h 8. Washington. D. C. The Brooking 1981, Op. cit. Table 27, p. 15. Ostow, M., and Millman, M. The demographic dimensions of health manpower policy. Public Health Reports, 1981, 96~4), 304-309. 16. Vector Research, Inc. Hospital nursing shortage designation criteria: Analysis and revision (DHPA Report No. 80-45~. Hyattsville, Md.: Health Resources Administration, 1980, pp. 10-11. 17. Feldbaum, E.G. Registered nurses at work. A report to administrators of health facilities. College Park, Md.: Bureau of Governmental Research, University of Maryland, 1980, p. 32. 18. North Carolina Area Health Education Centers Program. North Carolina AHEC 1982 nurse manpower survey: Final report. Chapel Hill, N.C.: N.C. AHECs Program, 1982. 19. Knopf, L., and Vaughn, J.C. Work-life behavior of registered nurses: A report to the nurse career-pattern study (Appendix, Final Report) (NTIS No. HRP-0900631~. Hyattsville, Md.: Health Resources Administration, 1979, p. 124. 20. National League for Nursing. NLN nursing data book 1981 (Publication No. 19-1882~. New York: National League for Nursing, 1982, Table 184, p. 185. 21. Secretary of Health, Education, and Welfare. An assessment of National Area Health Education Center Program (DHEW Publication No. HRA-80-33~. Washington, D.C.: U.S. Government Printing Office, 1980, pp. 11-46. 22. Cross, K.P. Living in the learning society. Paper presented at the Quality in Off-Campus Prograns Annual Conference, Nashville, Tenn., October 1981. Secretary of Health, Education, and Welfare. Health, United States, 1979 (DHEW Publication No. PHS-80-1232~. Washington, D.C.: U.S. Government Printing Office, 1979, Table 14, pp. 96-99. 23.
186 24. Blendon, R.J. Op. cit., p. 7. 25. Feldbaum, EeGe Ope cit., p. 19. 26. Sloan, F.A. The geographic distribution of nurses and public policy (DREW Publication No. HRA-75-53~. Washington, D.C.: U.S. Government Printing Office, 1975, pp. 150-155. 27. Ibid. 28. Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980 (Report No. 82-5, revised June 1982~. Hyattsville, Md.: Health Resources Administration, 1982, Table 1, p. 9. 29. Ibid. 30. California State Functional Task Analysis Study. General characteristics of nurses licensed in California, JanuarY 1975. Sacramento, Calif.: State of California Department of Health, 1977. 31. Eastwell Research Associates, Inc. Nursing manpower study--The status of nursing in Arizona. Phoenix, Ariz.: Arizona Department of Health Services, 198' 32. Feldbaum, E.G. Op. cit., p. 20. 33. Department of Health and Human Services, Health Resources Administration. Nursing scholarship program: Fiscal years 1970 through 1977, academic years 1977-78 through 1980-81. Unpublished manuscript, 1981. 34. Congressional Budget Office. Nursing education and training: Alternative federal approaches. Washington, D.C.: U.S. Government Printing Office, 1979. 35. Ibid. 36. DENS, HRA. The registered nurse population, an overview. national sample survey of registered nurses November 1980. Op. _ , cit., Table 1, p. 9. 37. Oversight on Financially Distressed Hospitals: Hearings before the Subcomm. on Health and Scientific Research of the Senate Comm. on Labor and Human Resources, 96th Cong., 2d Sess. 74~1980) (Statement of Henry E. Manning, Cuyahoga County Hospital) 38. Commission on Public-General Hospitals. The future of the public-general hospital (HRET Publication No. 9202). Chicago, Ill.: Hospital Research and Education Trust, 1978. 39. National Association of Public Hospitals. NAP H white paper: The situation of urban public hospitals in America today. Washington, D.C.: National Association of Public Hospitals, 1982. 40. Rogers, D.E., Blendon, R.J., and Maloney, T.~. Who needs Medicaid? New England Journal of Medicine, 1982, 307~1), 13-18. 41. Balz, D. Medicaid cuts put urban, public hospitals at the crunch point. The Washington Post, August 29, 1982, p. A4. 42. National League for Cities. Preliminary findings, municipal general hospital survey. Unpublished manuscript, 1981. 43. New York City Health and Hospitals Corporation. HHC nurse staffing: The numbers speak for themselves. New York: Consumer Commission on the Accreditation of Health Services Inc.' 1980, p. 8.
187 44. Rice, D. Morbidity, mortality, and population trends in the United States. Paper presented at the Annual Spring Meeting of - the Council~ of Teaching Hospitals, Atlanta, Gal, May 1981. 45. Gurel, L., Linn, Lid., and Linn, B.S. Patients in nursing homes. Journal of the American Medical Association, 213~1), 73-77. 46. Kayser-Jones, J.S.A. Gerontological nursing research revisited. Journal of Gerontological Nursing, 1981, _44), 217-223. 47. grower, H. A study of graduate programs in gerontological nursing. Journal of Gerontological Nursing, 1977, 3~6), 40-46. 48. Kayser-Jones, J.S. Op. cit., p. 218. 49. Reif, L., and Estes, C.L. Long-term care: New opportunities for professional nursing. In L. H. Aiken (Ed.), Nursing in the 1980s: Cries, opportunities, challenges. Philadelphia, Pa.: J. B. Lippincott Company, 1982. 50. Department of Health, Education and Welfare, Administration on Aging. ADA Occasional papers in gerontology, No. 1, Human resources issues in the field of aging: The nursing home industry (DHEW Publication No. OHDS-80-20093~. Washington, D.C.: Office of Human Development Services, 1980. 51. National Center for Health Statistics. The national nursing home survey: 1977 summary for the United States (DHHS Publication No. P B-79-1974~. Washington, D.C.: U.S. Government Printing Office, 1979. 52. Beaver, Kid. Task analysis of nursing personnel: Long-term care facilities in Utah (Doctoral dissertation, Brigham Young University, 1978) (University Microfilm NOe BKK78-16191~. Dissertation Abstracts International, 1978, 39/03-B, 1208, Table 6, pp. 96-100; and Table 7, pp. 102-106. 53. Department of Health, Education and Welfare, Administration on Aging. ADA Occasional papers in geronotology, No. 1, Human resources issues in the field of aging: The nursing home industry. Ad. cit., p. 8. 54. Department of Health and Human Services, Health Resources Administration. The registered nurse population, an overview. From national sample survey of registered nurses, November 1980. Op. cit., Table 9, p. 17. 55. Somers, A. R. Long-term care for the elderly and disabled. A new health priority. New England Journal of Medicine, 1982, 307~4), 221-225. 56. Ibid., p. 222. 57. American Association of Homes for the Aging. Survey of subcommittee on program performance recommendations regarding proposed conditions of participants for SNFs and ICFs. Washington, D.C.: American Association of Homes for The Aging, July 1982. 58. Nurse shortage and its impact on care for the elderly: Hearings before the Subcomm. on Health and Long-Term Care of the House Select Comm. on Aging, 96th Cong., 2d Sess. 50~1980) (Statement of Jack MacDonald, National Council of Health Centers)
188 59. American Nurses r Association. Facts about nursing 80-81. New York: American Journal of Nursing Company, 1981, p. 77. 60. Reif, L., and Estes, C.L. Op. cit., p. 152. 61. Brady, S., Health Care Financing Administration. Personal communication, December 15, 1982. 62. White House Conference on Aging. Final report (Vol. 3: Recommendations, post-conference survey of delegates). Washington, D.C.: White House Conference on Aging, 1981. 63. Freeman, R.B., and Henrik, J. Community health nursing practice. Philadelphia: W.B. Saunders Company, 1981, p. 178. 64. Department of Health and Human Services, Health Resources Administration. Health personnel issues in the context of long-teLlll care in nursing homes. Hyattsville, Md.: Health Resources Administration, 1980. 65. Sultz, H. A., Zielezny, M., Gentry, J. M., and Kinyon, L. Longitudinal study of nurse practitioners, Phase III (DREW Publication No. HRA-80-2~. Washington, D.C.: U.S. Government Printing Office, 1980. 66. General Accounting Office. Progress and problems in training and use of the assistants to primary care physicians. Washington, D.C.: General Accounting Office, 1975. 67. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services: Vol. 6. Nonphysician health care provider technical panel (DHHS Publication No. HRA-81-656~. Washington, D.C.: U.S. Government Printing Office, 1981. 68. Holmes, G. C., Livingston, G., and Mills, E. Contribution of a nurse clinician to office practice productivity: Comparison of two solo primary care practices. Health Services Research, 1976, ll(Spring), 21-33. 69. Institute of Medicine. A manpower policy for primary health care. Washington, D.C.: National Academy Press, 1978, p. 44. 70. Schultz, P. R. Primary care to the elderly: An evaluation of two health manpower patterns. Denver, Colo.: Medical Care and Research Foundation, 1977. 71. Kane, R. L., Solomon, D. H., Beck, J. C., Keeler, E. B., and Kane, R. A. Geriatrics in the United States: Mano owe r projections and training considerations. Lexington, Mass.: Lexington Books, 1981. 72. Martinson, I. University of Minnesota School of Nursing. Personal communication, October 20, 1982. 73. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisor Committee to · S_ ~ Nonphysician health care provider technical panel. Op; cit., pp.
189 74. LeRoy, L., and Solkowitz, S . The implications of cost- effectiveness analysis of medical technology. Background paper #2: Case studies of medical technologies. Case study #16: The costs and effectiveness of nurse practitioners (OTA Publication No. OTA-BP-H-9-16) . Washingtorl, D. C.: U. S . Government Printing Office, 1981. 75. Ibid. 76. Graduate Medical Education National Advisory Committee. Report of the Graduate Medical Education National Advisory Committee to the Secretary, Department of Health and Human Services: Vol. 6. Nonphysician health care provider technical panel . Op. c it., p. 21. 7 7. Department of Health and Human Services, Of f ice of Inspec tar General . Review of nurse s de linquent in repayment of nursing student loans, Public Health Service (Audit Control No . 12-33144) . Washington, D. C.: Off ice of Inspector General , 1982.
