Category Archives: Nursing

Stories on changing role of nursing illustrate ‘scope of practice’ issues

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org.

On Wednesday, I wrote about “scope of practice” – what health care providers, particularly nurse practitioners, who aren’t physicians are or are not allowed to do in their state. I provided several resources, reports and links to understand these fights, and the role nurses or physician assistants or other providers can have in providing primary care in underserved areas. Today I want to look at two stories:

Joanne Kenen

Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

The first was published earlier this fall online by Tina Rosenberg on The New York Times Opinionator section, part of a series called “Fixes” on solutions to social problems . She profiles a clinic in Indiana that provides full-service health care to 10,000 people – without any doctors. It’s one of about 250 clinics in the country run by nurse practitioners. Rosenberg reviews the reasons that there aren’t enough primary care doctors serving the poor or practicing in rural areas. She writes:

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

She says nurses are trained to do what many doctors do not learn – how to treat a patient more holistically, how to listen, how to “coach more, and lecture less.” All those skills are part of what’s needed to treat and manage chronic disease – which is what so much of primary care is about. Because nurses at the clinic are salaried, they aren’t stuck in the 15-minute-appointment hamster wheel of fee-for-service medicine. “At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.” Continue reading

‘Scope of practice’ stories vary according to state laws

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at healthjournalism.org. She welcomes questions and suggestions on health reform resources and tip sheets at joanne@healthjournalism.org.

One of the interesting stories to watch in the coming months in the states is the fight over “scope of practice.” That means: who gets to do what, and under whose supervision.  It basically pits doctors against other health care providers – nurses, nurse practitioners, physician assistants, etc. They are sometimes called “extenders” or “non-physician providers.” (There are also big fights within dentistry.)

Joanne KenenJoanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. If you have questions or suggestions for future resources, please send them to joanne@healthjournalism.org.

These fights would heat up even without the Affordable Care Act – you’ve all heard about the shortage (in some communities at least) of primary care physicians. And you know there is an aging population that is going to need access to primary care. Throw in the health care law – millions of newly insured people entering the system,  as well as delivery system reforms and care innovations that encourage more primary care, care coordination and team-based medicine that invites a larger role from those “extenders.”  (Can you tell I don’t like that word?)

But state law – some state laws – may limit what these health care workers can do or require so much supervision by a physician that it is tantamount to a limit. The nurses and physician assistants use the phrase “practice to the top of their license” to mean they want to be able to do everything they are trained and licensed to do.  There also are questions about how insurance plans address these different kinds of providers, and what options/explanations/information patients are given about who they are going to see at any particular juncture in their care.

In my next Covering Health post, I will share two recent stories I liked a lot about the changing role of nursing (which isn’t the only scope-of-practice fight but it’s the one you hear most about). First I want to provide some resources and thoughts on how to cover this topic more broadly.

Keep in mind that there are national trends but it’s a state-based legal problem. Continue reading

Investigation reveals N.Y. lax on home care oversight

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

In the Albany (N.Y.) Times Union, Matt Drange’s investigation is titled “Home health care in crisis.” Having read the piece, I can say it’s safe to take that declaration at face value. At the very time that home care is booming in New York as a cheaper, more convenient alternative to nursing homes, the state has cut back on its number of health inspectors. Meanwhile, the complexity of home care cases is rising, as hospitals release patients earlier and the population as a whole ages. The results, Drange writes, have been predictable.

Lapses have gone undetected or, in many cases, unpunished by the Department of Health, the arm of state government tasked with overseeing home health agencies. Providers are not required to notify the department when patients experience sudden or unexpected changes in their condition, including death. And even when the state does learn about these incidents, it doesn’t always act on the information, records show.

For the investigation, Drange looked at public records regarding Medicaid billing, home care agency registration and plenty of state inspection reports. He focused his review on 40 of the worst offenders, and found more than enough examples to illustrate a system in crisis. Drange’s anecdotes recount numerous egregious lapses in care, and I strongly recommend digging into the meat of the piece, if only to see what incredible detail he found in public records. For now though, at the risk of mild spoilers, I’ll just reveal that they all end in the same way: The problem goes undetected, unenforced, or underpunished.

In the end, as reporters have found in other states as well, the root of the problem seems to be a weak and vaguely defined regulatory system. In his investigation, for example, Drange found a sharp contrast between the oversight of nursing homes and home care, two institutions which often perform similar functions.

(Researcher Sam Krinsky of the United Healthcare Workers East 1199 Union) said the culture of home care differs vastly from that of nursing homes, which have received more attention in New York and elsewhere.

Statements of deficiencies issued to home care agencies by the Department of Health are “not something that we take seriously,” Krinsky said.

“In nursing homes, the inspections are a big deal. There are a lot more regulations they have to comply with … It’s just a much more robust system,” he said. “In home care, it’s more of a review of paperwork. It [Department of Health] doesn’t have any teeth.”

Your thoughts on this story?

Drange, an AHCJ member and recent graduate of the Columbia Journalism School, did this investigation as his master’s project. He invites feedback from other health care reporters about the story and anything he could have done differently. Feel free to comment below or send your thoughts to him at mattdrange@gmail.com or on Twitter (@mattdrange).

American dentistry, a parallel medical universe

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

NationalJournal’s Margot Sanger-Katz reports on the sometimes woeful state of American dental care, especially for low-income children. And yes, her piece is datelined “HAZARD, Ky.” But that’s where its anecdotal focus ends and Sanger-Katz paints the bigger picture.

dentistPhoto by dbgg1979 via Flickr

The United States faces a shortage of dentists that is particularly acute in poor, rural regions. Huge pockets of the country have few (or no) providers. The federal government counts 4,503 mostly rural regions where more than 3,000 people share one dentist, making it tough for many residents to find someone to fix their teeth.

For more than 100 years, dentistry has run on a separate—and more laissez-faire—track than the rest of medicine. Dentists have their own schools and treat patients in their own offices; fewer laws and regulations govern the field. Insurance plans typically demand high co-pays and limit their payouts for invasive procedures. About half of all dental expenses are paid out of pocket, compared with less than 10 percent of costs in the overall medical system.

In some ways, what Sanger-Katz calls a “free market” has worked. Folks shop around, and they only get dental care when they really needed. Prices don’t inflate as quickly as they do in medicine in general, and American dental health is still getting better. Continue reading

Reporters spend 10 weeks immersed in end-of-life care

Andrew Van Dam

About Andrew Van Dam

Andrew Van Dam of The Wall Street Journal previously worked at the AHCJ offices while earning his master’s degree at the Missouri School of Journalism, and he has blogged for Covering Health ever since.

Toronto Globe and Mail reporter Lisa Priest and photographer Moe Doiron spent two-and-a-half months embedded in a 20-bed critical care unit at a Toronto

ventilator

Photo by quinn.anya via Flickr

hospital, following four patients and their families and chronicling life in an environment where, Priest writes, “death is a constant, almost routine event, claiming one in five patients who enter.”

Their assignment was to find out “How does one prepare for the end of life?” and explore the medical, ethical and economic challenges of that stage of life.

The result is a sprawling, intensive report on the state of end-of-life care in Canada, heavy on anecdotes. Priest’s centerpiece is subtitled “Spending 10 weeks with patients facing death“) but remains cognizant of big picture issues like cost and quality of life.