THE SURGE IN THE NUMBER OF

CNE Objectives and Evaluation Form appear on page 84. Jennifer A. Coddington Laura P. Sands Cost of and Quality Outcomes of Patients At Nurse-Managed Clinics EXECUTIVE SUMMARY Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs. Nurse-managed clinics (NMCs) can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that nurse-managed clinics improve the use of preventative services, aid in the promotion of health, compliance of treatment and patient satisfaction, and reduce emergency room visits and rehospitalizations. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if nursemanaged clinics are to remain viable. THE SURGE IN THE NUMBER OF Americans lacking health insurance has become a priority on our national agenda. The continued rise in the number of uninsured, steep declines in employer-sponsored health insurance, and the lack of a national solution is alarming as policymakers scramble to develop health care reform. From 2002 to 2005, the number of uninsured Americans rose 7% to more than 46 million (Robert Wood Johnson Foundation [RWJF], 2007c). Even more concerning is that approximately 9 million children lack health insurance and an estimated 1.8 million children who are eligible for the State Children s Health Insurance Program are yet to be enrolled (RWJF, 2007a). Nearly 70% of low-income children are uninsured, and 75% of uninsured children live with someone who works full time (RWJF, 2007b). In addition, cost-containment measures to federal and state-funded health care programs have resulted in lower reimbursement rates and providers who are less willing to accept patients enrolled in these programs. Lack of health insurance is a critical factor in access to appropriate health services and is directly associated with poor functioning, increased morbidity and mortality, lack of continuity of care, and rising health care costs (RWJF, 2007a). In a previous, Medicaid program restructuring that resulted in a reduction of Medicaid enrollments increased emergency department use by uninsured persons and thereby increased the amount of uncompensated care provided by hospitals (Napier, 2007). Nationally, uncompensated health care costs health care institutions annually JENNIFER A. CODDINGTON, MSN, RN, CPNP, DNP(c), is Visiting Associate Professor and Director, Pediatric Nurse Practitioner Master s Track, Purdue University School of Nursing, West Lafayette, IN, as well as Coordinator, Trinity Nursing Center for Infant and Child Health. LAURA P. SANDS, PhD, is a Professor of Nursing, Director of Faculty Development of the School of Nursing, and a Co-director, Center for Healthcare Outcomes and Policy Research, Regenstrief Center for Healthcare Engineering, Discovery Park at Purdue University, West Lafayette, IN. NOTE: The authors and all Nursing Economic$ Editorial Board members reported no actual or potential conflict of interest in relation to this continuing nursing education article. 75

billions of dollars. The same also found that emergency department visits by uninsured children would increase from 9% to 25% (Napier, 2007). Patients without health insurance commonly rely on some type of safety net to obtain health care services. Nurse-managed centers (NMCs) play an important role in the delivery of health care services to this population. The first centers were established in the early 1970s and paralleled the development of nurse-practitioner education (Barkauskas et al., 2004). Nurse-managed centers typically serve patients who would otherwise be underserved or not served at all. NMCs provide primary care with an emphasis on health promotion, disease prevention, and a focus on the family unit and community. Unfortunately, NMCs often struggle to remain financially viable. Numerous reasons have been attributed to NMCs failure to remain financially stable, but lack of third-party reimbursement stands out as one of the most important factors. It is important to assess whether NMC s can provide high-quality, economically viable systems of care for underserved patients. To date, there have been no systematic reviews that focus on quality and cost expenditures of NMCs in relation to health care services and continuity of care. The purpose of this review is to assimilate evidence regarding the cost of providing care and the quality of care provided by nursemanaged clinics. Assessment of cost of care includes break-even analysis, operating costs of NMCs, average charges per patient encounter and per patient visit at NMCs, and cost comparisons between NMCs and the use of emergency rooms, urgent care, and hospital services. Quality of care will consider reports of patient satisfaction and descriptions of patient s experiences and care provided at NMCs. Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics Table 1. Assessing of Descriptive Studies Included quality of patient care/satisfaction in. +1 Included hospitalization/emergency room/urgent care use in relation to +1 cost analysis in. Included description of health care services in. +1 Methods A broad search of the PubMed database of the National Library of Medicine and CINAHL database from 1970-2007 was conducted using the following MESH terms: Nurse practitioner AND Costs and Cost analysis; Nurse practitioner AND Costs and Cost Analysis AND ( Quality assurance, healthcare; OR Quality indicators, healthcare; OR Quality of healthcare; OR Health care quality, access, and evaluation ). Related articles to relevant studies on PubMed were also reviewed and revealed two more articles. In addition all references within relevant papers were investigated for added articles (two articles). Although the focus of this review is about NMCs and cost and quality care outcomes, other NMC settings (defined as academic nurse-managed clinics, community health clinics, and any clinic that is nurse managed and provides primary care to the public) and methods of reimbursement were included to assess the overall cost and quality of care outcomes of NMCs. The search dates 1970-2007 were looked at specifically because it was in the early 1970s that nurse practitioner (NP) programs started to come to the forefront and NPs began to be recognized for their contributions to primary care. It was also in the early 1970s that the first NMCs were established. For this systematic review, quantitative as well as qualitative studies were included. Inclusive criteria for the studies in this review included that the health care providers evaluated in the must be advanced practice nurses (APNs), must be providing primary care in a nurse-managed health clinic setting, and outcomes must focus on cost analysis or cost analysis and quality of care of the clinic. Exclusion criteria included studies of health care that took place in a private office setting, or studies of health care providers who were not APNs, or studies of NPs who did not provide primary care, or studies whose outcomes did not include cost analysis or cost analysis and quality of care of NMCs. A total of 711 articles were retrieved during the literature review process. As stated previously, studies that did not have an APN as the health care provider were not reviewed (22 articles), studies that did not take place in a NMC setting were not included (112 articles), studies whose outcomes did not include cost analysis or cost analysis and quality of care outcomes of NMCs were excluded (566 articles), and studies in which NPs did not provide primary care were excluded (5 articles). The designs of the included articles were reviewed to determine the level of evidence they contribute to the literature (Melnyk & Fineout-Overholt, 2005). Levels of evidence were stratified into four levels. Level I referred to systematic review of randomized controlled trials, level II included randomized controlled trials, level III indicated the was a nonrandomized controlled trial or from a cohort or case control analytical, and level IV were articles whose findings were based on expert opinion. Furthermore, studies were assigned a relevance score on a 0 to 3 scale (see Table 1). For each included in this literature review, the fol- 76

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics SERIES Study, Authors, Date Academic Nursing Clinic: Impact on Health and Cost Outcomes for Vulnerable Populations (Badger & McArthur, 2003) Nursing s Response to the Crisis of Access, Costs, and Quality in (Schroeder, 1993) A Cost Analysis of a Nursing Center s Services (Ervin, Chang, & White, 1998) A Cost Analysis of a Nurse- Managed, Voluntary Community Health Clinic (Saywell, Lassiter, & Flynn, 1995) Table 2. Evidence of Cost of Providing Care and Quality of Care at Nurse-Managed Clinics Study and Client Outcome Measures/Period of Data Collection Facility/Providers Services Provided Outcomes score: 3 2/3 were women, majority > 60 years; mainly lowincome/vulnerable populations 1. Quality of care 2. Costs 3. Client satisfaction first 12 months of operation Academic nursing clinic/nurse practitioners: a family nurse practitioner and a psychiatric-mental health nurse practitioner, mental health/ chemical dependency 1. Clients seen weekly if needed, patients developed therapeutic relationships with NPs, access barriers such as transportation were removed all resulting in improved quality of patient care. 2. Average patient visit cost $15.17; costly misuse of emergency services, police was prevented; reduction in paramedic calls; self-reports showed fewer hospitalizations. 3. 93% of patients were completely or very satisfied with the care received at the clinic. score: 3 Persons with HIV/AIDS; males > females 1. Estimated savings in hospital charges 2. Cost effectiveness of center 2 years Nurse-managed community center for persons living with HIV/AIDS/doctorate and master s-prepared APNs Medical and supportive services are provided 1. Estimated hospital charges saved in 1991 were $785,744, and in 1992 were $1,163,912. 2. 94%-100% of clients surveyed stated that they preferred to have medical treatments performed at the center, rather than in a hospital; also clients surveyed in 1992 and 1993 reported a positive impact on quality of life. score: 1 All ages/ pregnant women/low income population 1. Break-even analysis 2. Cost October 1995-May 1996 NMC/Family NP, nurse midwife for all ages/ prenatal care 1. One approach to reach break-even point for finances is to decrease cost of operating the center. 14% of the centers expenses consist of building expenses, including utilities, repairs, and property taxes. 2. To reach break-even volume the NPs would need to complete 3.35 visits each hour. score: 1 73% were 18-54 years of age; 13% were in the 6-17 year age group; 2/3 were women; services not available to patients with personal health insurance 1. Cost accounting 2. Operating cost analysis 3. Clinic cost compared with physician cost May 1993-April 1994 Nurse-managed community health center/nps and volunteer physicians 1. Average direct cost per patient visit $41.86; average total cost per patient visit (including opportunity costs) $70.99; costs included the cost of patient medicine in the visit. 2. Average charge for a routine office visit in the area was approximately $38. 3. The clinic was operating at 40% of capacity, maximum capacity under current staffing levels was about 3.5 patients per hour. At maximum capacity, direct costs and total unit costs (including medicine) were $21.13 per visit and $ 32.59 respectively; excluding medication costs per visit were $15.97 and $27.44 respectively. 77

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics Study, Authors, Date Efficacy of Primary Care in a Nursing Center (Helvie, 1999) Financial Performance of Academic Nurse-Managed Primary Care Centers (Vonderheid, Pohl, Barkauskas, Gift, & Hughes-Cromwick, 2003) Cost Analysis of a Nursing Center for the Homeless (Hunter, Ventura, & Kearns, 1999) Table 2. (continued) Evidence of Cost of Providing Care and Quality of Care at Nurse-Managed Clinics Study and Client Outcome Measures/Period of Data Collection Facility/Providers Services Provided Outcomes One portion of the appears to be quasi-experimental. The outcomes of services portion of the included a pre and post survey of patients using the SF-36 Health Survey. score: 3 Clients of all ages; homeless and lowincome populations 1. Percentage and types of clients referred 2. Reported client satisfaction 3. Outcomes of services provided 4. Influence on ER visits 5. Cost-effectiveness of services March 1997-September 1998 NMC/Family NP 1. Less than 3% of center s patients were referred for emergency care. 2. Results of a patient satisfaction survey showed that most patients were very positive about the experience and care provided. 3. A pre and post survey reported a significant difference following interventions in the following areas: less nervous, more pep, and happier. 4. According to staff at the local ER, visits by this population of patients decreased since the nursing center opened; according to the NP these numbers decreased over the past few months as clients become more aware of the center. 5. Cost per patient visit was approximately $65, compared to cost per patient visit at the local emergency room which ranged from $215-$323. Descriptive retrospective nonexperimental score: 1 Varied patient mix with clients of all ages from diverse populations 1. Cost performance measures per patient (included service revenue, general operating costs, total operating costs) and per encounter were compared between the clinics and family practice physicians (obtained through national benchmarking data) 2000 calendar year NMCs/APNs 1. Service revenue per patient ranged from $38-$231 among the centers, which was 200% higher than family practice physicians (FPP); general operating costs per patient ranged from $45-$79, which was higher than the $29 for FPPs; operating costs ranged from $156-$201 and were higher than FPPs at $109; no nursing center was profitable, but FPPs reported a $0.85 profit per patient. score: 2 Men, women, and children; homeless populations 1. Cost of providing health care to the homeless at a NMC compared to the cost of going to the local ER, CHC, hospital clinic, or health department 2 years (1992-1993) NMC for the homeless/apns 1. Cost per visit for the NMC for the homeless was $62.71 compared to Erie County Health Department s Medically Indigent Program at $61.82, Erie County Health Department s Community Health Clinics at $84.71, Erie County Medical Center General Clinics cost of $92, and Erie County Medical Center Emergency Room cost per visit of $213.27. 78

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics SERIES Study, Authors, Date Emergency Department and Community Health Center Visits and Costs in an Uninsured Population (Smith-Campbell, 2005) Academic Nurse-Managed Centers: Approaches to Evaluation (Barkauskas et al., 2004) Quality and the Nursing Workforce: APNs, Patient Outcomes and Costs (Brooten, Youngblut, Kutcher, & Bobo, 2004) Table 2. (continued) Evidence of Cost of Providing Care and Quality of Care at Nurse-Managed Clinics Study and Client Outcome Measures/Period of Data Collection Facility/Providers Services Provided Outcomes score: 2 Clients are all uninsured; ages of clients are not described 1. Local emergency department use by uninsured patients 2. Emergency department perceived cost savings 1988, 1990, 1993, 1995, and 1996-2001 Local community health center/apns 1. After the nurse-managed health center opened in 1990, visits to the ED by uninsured clients decreased 25% by 2000. 2. The hospital saved an estimated $13.9 million because of the drop in total uninsured ED visits; this cost is based on the average ED visit charge in 2000 ($1,620), not on actual cost. score: 2 Varied in ages among academicnurse managed centers (ANMCs); population consisted of homeless, uninsured, veterans, chronically mentally ill, and university students 1. Care provided by ANMCs 2. Financial analysis 4 years (1998-2002) ANMCs/APNs, faculty 1. Patients expressed high satisfaction with the care they received and 99% indicated they would probably use the center again; community focus group participants commented on the high quality of care received in the ANMCs; HEDIS protocols demonstrated that the quality of care provided in the ANMCs was generally comparable with national benchmarks. 2. Total operating costs per encounter varied greatly across the ANMCs from $47-$177; only one of the centers made a profit, and losses ranged from $18-$75 per encounter. score: 3 Clients of all ages 1. Quality of care: defined as patient compliance, health promotion/prevention, patient independence, adjustment to illness, stress management, and patient s overall satisfaction 2. Health care costs defined as level of reimbursement, prescriptions written, diagnostic tests ordered, ER or UC use Not described: article described the role of the APN in primary care, acute care, home care, and transitional care but did not described in exactly what setting/apns 1. APN provided care results in greater use of preventative services, greater patient independence, promotion of health, adjustment to illness, stress management, functional status, compliance with treatment, patient satisfaction, reduced ER visits, and rehospitalizations. 2. APNs are reimbursed at a lower rate than physicians for the same services, thereby saving health care costs, additionally APNs order fewer tests and prescription medications than physicians. 79

lowing information was recorded: type of and relevance of, type of health care facility, type of health care providers, type of health care services provided, type of client, outcome measures defined as cost analysis or cost analysis and quality of patient care/period of data collection, statistical findings given in the, and outcome measures/findings related to the research question. Results Cost analysis and potential health care cost savings of nursemanaged clinics. A search of the literature revealed a lack of level I quality systematic reviews regarding NMCs and cost expenditures. All of the studies in this review were level III evidence. From the literature search, two descriptive non-experimental studies discussed break-even analysis, two descriptive studies discussed operating costs per patient for NMCs, three descriptive studies discussed average charges per patient encounter in a NMC compared to other primary care settings in the local area, one descriptive nonexperimental described average charges per patient in a NMC setting, and five descriptive nonexperimental studies compared costs between NMCs and the use of Emergency rooms, urgent care centers, or hospitalizations (see Table 2). Two studies described breakeven analysis of NMCs. Ervin, Chang, and White (1998) discussed the volume of patients that needed to be seen annually to achieve break-even costs for the NMC described in this. To reach the break-even point, 7,227 client visits would be needed in 1 year or 3.35 visits each hour would need to occur. The researchers described decreasing the cost of operating the center as one approach to reaching the breakeven point for costs since 14% of the center s expenses consisted of building expenses, including utilities, repairs, and property taxes. It Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics was felt this could be achieved by acquiring donated space which included utilities or moving the nursing center to another location within the community. Saywell, Lassiter, and Flynn (1995) found the nurse-managed community health center in the was operating at 40% of capacity. It was felt that maximum capacity under current staffing levels to achieve the break-even point financially was about 3.5 patients per hour and the clinic was currently operating at about 1.4 patients per hour. Two studies reported total operating costs per patient for NMCs which included office expenses, personnel, and in-kind goods and services. Vonderheid, Pohl, Barkauskas, Gift, and Hughes-Cromwick (2003) found that operating costs per patient for the NMCs in this ranged from $156 to $201 and were higher than local family practice physicians at $109 per patient. No center in that was profitable whereas family practice physician offices showed a profit of $0.85 per patient. Barkauskas and colleagues (2004) looked at several academic NMCs and found that total operating costs varied greatly and ranged from $47 to $177 per patient. Only one of the centers in the made a profit and losses were due to low volume of patients and problems with reimbursement. Three studies compared the average charge per patient visit to other primary care settings in the local area. One described average charge per patient encounter. Saywell and colleagues (1995) described the average direct cost of care per patient visit to be $41.86 and $70.00 if the cost of the patient s medicine was included. The first cost of $41.86 per patient visit was then compared to the average cost for a routine primary care physician office visit in the local area of $38. The authors calculated that if the clinic was operating at total maximum capacity, direct cost per patient with and without medications would be $21.13 and $15.97 respectively. Helvie (1999) compared cost per patient visit of $65 at the nurse-managed center versus cost per patient visit at the local emergency room of $215 to $323. Finally, Hunter, Ventura, and Kearns (1999) described the cost per visit for a nurse-managed clinic for the homeless to be $62.71 which is comparable to a local County Health Department s Medically Indigent Program at $61.82. The NMC s charge was significantly lower than the local County Health Department s Community Health Clinics at $84.71, the local County Medical Center General Clinics at $92, and the local County Medical Center Emergency Room at $213.27 per patient visit. Badger and McArthur (2003) described the charge per patient visit at the academic NMC described in the as $15.17. This figure was extrapolated from 693 patient visits at a total cost of $10,512. The researchers did not compare the average charge per patient visit to other primary care settings in the local area. Five descriptive studies described potential cost savings of NMCs associated with reduced use of emergency rooms, urgent care centers, and hospitalizations. Badger and McArthur (2003) noted that prior to the NMC in this opening, a major problem was the misuse of costly emergency services, police, and paramedics. When comparing the number of emergency medical services provided before the clinic opened, the clinic reduced paramedic calls by 32% in the first 6 months. In dollars this translates into a health care cost savings of $16,650. A 39% reduction in police calls was also found, resulting in a cost savings of $9,400. Schroeder (1993) estimated that the hospital charges saved in 1991 due to the Nurse-Managed Community Center for Persons Living with HIV/AIDS was $785,744 and 80

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics the estimated hospital charges saved in 1992 were $1,163,912. Hunter and colleagues (1999) demonstrated that the cost per visit for the Nurse- Managed Clinic for the Homeless was $62.71 compared to Erie County Medical Center Emergency Room cost per visit of $213.27. Helvie (1999) did not report data, but staff at the local emergency room stated that visits by the population of patients seen at the NMC described in this article decreased since the nursing center opened and continued to decrease as clients became more aware of the clinic and its services as evidenced by less than 3% of the center s patients being seen for emergency care. Finally, Smith-Campbell (2005) showed that between 1990 and 2000, after a local community health center had opened, visits to the emergency room by uninsured clients decreased 25% and the local hospital saved an estimated $13.9 million because of the drop in total uninsured ED visits. Patient satisfaction and quality of care among patients at nursemanaged clinics. The literature search retrieved three descriptive non-experimental studies that reported percentage of satisfaction among patients in relation to NMCs and expenditures of care, and four descriptive studies nonexperimental studies that described ways in which patients at NMCs were satisfied with the care they received (see Table 2). All of these studies were level III evidence. This demonstrates the lack of quality level I evidence for systematic reviews relating to quality of care or patient satisfaction in relation to NMCs and expenditures. Three studies reported results from satisfaction surveys given to patients at NMCs. Badger and McArthur (2003) reported that 93% of clients were completely or very satisfied with the care they received at the academic NMC in Nurse-managed clinics can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. the. Schroeder (1993) reported that 94% to 100% of clients surveyed stated they preferred to have medical treatments performed at the Nurse-Managed Community Center for Persons Living with HIV/AIDS on an outpatient basis rather than in the local hospital. Barkauskas and colleagues (2004) reported patients overwhelmingly expressed high satisfaction with the care they received and 99% indicated they would probably use the center again. Four studies described the ways in which patients at NMCs were satisfied with the care they received. Badger and McArthur (2003) found that academic NMCs allowed patients to (a) develop therapeutic relationships with the nurse practitioners, (b) remove barriers to care such as transportation, and (c) improve health care access. Schroeder (1993) surveyed clients in 1992 and 1993 and noted a positive impact on quality of life. Helvie (1999) developed a patient satisfaction tool using a Likert scale and administered to patients on their third visit. Results showed that most patients were very positive about their experience and care provided. In the same, a pre and post survey of patients using the SF-36 Health Survey was conducted. Results showed a significant improvement in clients healthrelated quality of life including being less nervous, having more SERIES pep, and feeling happier. In a by Barkauskas and colleagues (2004), community focus group participants commented on the high quality of care received at the academic NMCs described in the, and HEDIS protocols demonstrated that the quality of care provided in the academic NMCs was generally comparable with national benchmarks. Finally, Brooten, Youngblut, Kutcher, and Bobo (2004) demonstrated care provided by APNs resulted in greater use of preventative services, greater patient independence, promotion of health, adjustment to illness, stress management, functional status, compliance with treatment, patient satisfaction, and reduced emergency room visits and rehospitalizations. Discussion Nurse-managed clinics can serve as an important safety net in the health care delivery system by offering needed health services to the poor and underinsured populations. The current focus on the restructuring of Medicaid programs has resulted in funding cuts, reduction in provider reimbursement, and restrictions on eligibility. Consequently, fewer physicians are accepting Medicaid patients and more and more patients are turning to the emergency department for routine care. Being uninsured or underinsured can have serious health consequences and contribute to the rising cost of health care. With approximately 15% of the U.S. population underinsured, there is a need to conduct cost and quality analysis of nurse-managed clinics to assess whether they can feasibly provide a partial solution to the problem. Even more alarming, we are in danger of abandoning our most vulnerable population children, if we do not find a solution to the problem. Despite these daunting statistics, little systematic work has been conducted that 81

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics Nurse-managed clinics are viewed as an integrally important component of the health care system for vulnerable populations. evaluates how to make nursemanaged clinics more costeffective while simultaneously improving quality of care for these vulnerable patients. Cost analysis of nursemanaged clinics. Interestingly, of the two studies that discussed break-even analysis, both discussed the need to increase productivity by increasing the volume of patients seen. Ervin and colleagues (1998) felt that 3.35 visits each hour were needed to achieve break-even analysis, whereas Saywell and colleagues (1995) were very much consistent with 3.5 patient visits per hour. One of the perennial difficulties of NMCs described in each article was the need for volume enhancement. To achieve this, more clients on Medicaid, Medicare, and third-party payers need to compose the patient caseload so revenue can be enhanced. Findings that show that NMCs overall are more expensive than other local practices must be interpreted in light of low volume of patients and reimbursement issues at NMCs. If these problems are solved, NMCs have the potential to be cost-effective solutions to providing care for both insured and uninsured clients. Solutions for making NMCs more cost effective include operating the clinics at total maximum capacity and developing well-designed capitated contracts and revenue from third-party payers. Several authors described reduced use of emergency rooms, urgent care centers, and hospitalizations, which are the alternative resources if NMCs are not available, providing further evidence of the potential cost effectiveness of NMCs. Proposed health care reforms have suggested greater use of advance practice nurses in the primary care setting. This supports the need for systematic efforts to develop cost-effective NMCs. Patient satisfaction and quality of care among patients at nursemanaged clinics. Evidence to date suggests that patients overall are highly satisfied with the care they receive at NMCs. In one, clients preferred to have their medical treatments performed at the NMC on an outpatient basis rather than in a hospital, thus demonstrating quality of care and cost containment. Several other studies demonstrated that overall patients at NMCs were satisfied with the care they received and were very positive about their experiences and care. Indicators of quality of care at NMCs include removing barriers to care, improving health care access, and developing therapeutic relationships with nurse practitioners. Much evidence also exists that NMCs improve the use of preventative services, aid in the promotion of health, compliance of treatment, patient satisfaction, and reduce emergency room visits and rehospitalizations. All of this provides further verification of the ability of NMCs to provide high-quality care while improving the cost effectiveness of providing health care. Nurse-managed clinics have the potential to serve as an important safety net for patients and can positively influence the health and cost outcomes for vulnerable populations. The findings of this review contribute to an understanding of what is needed to improve the financial viability of NMCs. One of the consistent themes in this review is the need for patient volume enhancement and the importance of reimbursement through Medicaid and third-party payers if NMCs are to remain viable. Another recurring theme of this review is that NMCs can reduce the number of clients using the more costly emergency-based services thereby reducing health care costs. Lastly, this review demonstrated that patients of NMCs overwhelming expressed high satisfaction with quality of health care received and experiences of care resulting in improved cost expenditures and cost containment. Limitations The lack of a standardized approach to measuring quality of care and patient satisfaction presents difficulty when comparing results across studies. For example, some studies surveyed if patients preferred to have medical treatments performed at the NMC versus the hospital as a measure of quality of care. Other studies surveyed patients regarding subsequent use of the NMC as a measure of quality. Still other studies employed quality of life surveys and national benchmarks as indicators of quality. Although methods used to assess quality of care varied widely, preventing statistical evaluation of findings across studies, the conclusions from each were consistent that NMCs provide quality care to patients. Another limitation is the descriptive nature of all of the studies reviewed. Descriptive studies allow for personal interpretation of data and again may not be as sensitive in measuring cost and quality care outcomes of NMCs. However, studies in which patients are randomly assigned to either NMCs versus private physician offices would be financially unfeasible because the would have to bear the cost of the services provided. 82

Cost of and Quality Outcomes of Patients at Nurse-Managed Clinics Implications for Nurse Leaders Nurse-managed clinics are viewed as an integrally important component of the health care system for vulnerable populations. The findings in this review demonstrate clearly the need to enhance patient volume. Furthermore, more work is needed to remove policies restricting reimbursement for nurse practitioners. Specifically, revenue and volume enhancement can be addressed by allowing NPs to participate in state and federal programs such as Medicaid and Medicare, as well as with third-party payers. Evidence also suggests that NMCs decrease urgent care visits, emergency room visits, and hospital admissions demonstrating their role in containing rising health care costs. This review also confirmed that NMCs provide high-quality care with a high level of patient satisfaction. At a time when patients are looking for competent, high-quality health care among rising costs, nurse-managed clinics have established that they are important, viable, community-based safety nets for health care services. $ REFERENCES Badger, T.A., & McArthur, D.B. (2003). Academic nursing clinic: Impact of health and cost outcomes for vulnerable populations. Applied Nursing Research, 16(1), 60-64. Barkauskas, V.H., Pohl, J., Breer, L., Tanner, C., Bostrom, A.C., Benkert, R., et al. (2004). Academic nurse-managed centers: Approaches to evaluation. Outcomes Management, 8(1), 57-66. Brooten, D., Youngblut, J.M., Kutcher, J., & Bobo, C. (2004). Quality and the nursing workforce: APNs, patient outcomes, and health care costs. Nursing Outlook, 52(2), 45-52. Ervin, N.E., Chang, W.-Y., & White, J. (1998). A cost analysis of a nursing center s services. Nursing Economic$, 16(6), 307-312. Helvie, C.O. (1999). Efficacy of primary care in a nursing center. Nursing Case Management, 4(4), 201-210. Hunter, J.K., Ventura, M.R., & Kearns, P.A. (1999). Cost analysis of a nursing center for the homeless. Nursing Economic$, 17(1), 20-28. Melnyk, B.M., & Fineout-Overholt, E. (2005). Evidence-based practice in nursing and healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins. Napier, M. (2007). Do reductions in Medicaid/SCHIP enrollment increase emergency department use among low-income persons? Retrieved January 31, 2008, from http://www.rwjf.org/news room/feature.jsp?id=20914&typeid=15 1&gsa=1 SERIES Robert Wood Johnson Foundation (RWJF). (2007a). 1.8 million children are eligible for the state children s health insurance program. Retrieved January 31, 2008, from http://www.rwjf.org/news room/newsreleasesdetail.jsp?product id=21921&gsa=1 Robert Wood Johnson Foundation (RWJF). (2007b). Fewer employers offer lower income parents health coverage. Retrieved January 31, 2008, from http:// www.rwjf.org/newsroom/newsreleasesdetail.jsp?productid=21872&gsa=1 Robert Wood Johnson Foundation (RWJF). (2007c). New report details state efforts to reform health care. Retrieved January 31, 2008, from http://www.rwjf. org/newsroom/newsreleasesdetail.jsp? productid=21930&gsa=1 Saywell, R.M., Lassiter, W.L. III, & Flynn, B.C. (1995). A cost analysis of a nursemanaged, voluntary community health clinic. Journal of Nursing Administration, 25(10), 17-27. Schroeder, C. (1993). Nursing s response to the crisis of access, costs, and quality in health care. Advances in Nursing Science, 16(1), 1-20. Smith-Campbell, B. (2005). Emergency department and community health center visits and costs in an uninsured population. Journal of Nursing Scholarship, 37(1), 80-86. Vonderheid, S., Pohl, J., Barkauskas, V., Gift, D., & Hughes-Cromwick, P. (2003). Financial performance of academic nurse-managed primary care centers. Nursing Economic$, 21(4), 167-175. F O U N D A T I O N Nursing Economic$ Foundation Scholarship Applications Available Since its establishment in 1990, the Nursing Economic$ Foundation has promoted the advanced educational and research activities of nurse executives who are pursuing graduatelevel degrees. Scholarships ($5,000) are awarded to future nurse executives for tuition, fees, and other expenses incurred while completing their degrees. To date, the Foundation has awarded $240,000 as part of the journal s mission to advance nursing leadership in health care. Please urge your students and colleagues to learn more about and apply for these valuable scholarships. The Nursing Economic$ Foundation is funded through the generous support of individuals and corporations. To make a donation or request information regarding the scholarship awards, contact: Nursing Economic$ Foundation East Holly Avenue Box 56 Pitman, NJ 08071-0056 nefound@ajj.com 83