Bobbie Berkowitz

Collaborative partnerships at the state level: promoting systems changes in public health infrastructure.

Reforms in the public health infrastructure such as those called for in recent Institute of Medicine reports require stakeholder engagement on different levels than traditional grass-roots community work. The Turning Point Initiative, funded by The Robert Wood Johnson Foundation, involves 21 state-wide partnerships established for systems change and focused in specific areas of public health innovation and policy development. These partnerships represent a different model of strategic alliances and relationship-building than has been previously described in the literature on community-level and health-promotion collaborations. This article utilizes qualitative data to illustrate the ways in which state-level partnerships for systems change both confirm and extend previous models. Findings indicate that state-level public health partnerships share many of the challenges and opportunities of locally-based and health-promotion-oriented partnerships. Collaboration at the state level, however, involves more attention to organizational alliances, coordination of institutional change, and strategic responses to political changes. These partnerships depend on a combination of interpersonal skills, material resources, and organizational savvy to manage complex planning and implementation processes. Influencing policy development and organizational redesign in public health systems requires nuanced understanding of the opportunities provided by various kinds of organizational partners.

Collaboration for health improvement: models for state, community, and academic partnerships.

The value of approaching health improvement through collaborative models seems self-evident, especially at the community level. A review of the literature, however, reveals a number of challenges in terms of helping us understand precisely what it is that makes collaborative models effective in influencing health. The purpose of this article is to describe important elements of collaboration that state, local, and academic partners may wish to consider when developing models for health improvement. The author will provide examples of collaborative strategies that are emerging from the Turning Point: Collaborating for a New Century in Public Health initiative.

Rural Public Health Service Delivery: Promising New Directions

I describe variations in the structure and in the practice of rural public health and how rural communities meet the challenges of current public health practice, including primary methods of service delivery and partnership development. I present examples of promising models for the creation of rural public health capacity-the ability of local health departments to carry out core public health responsibilities.

Revisiting Scope of Practice Facilitators and Barriers for Primary Care Nurse Practitioners: A Qualitative Investigation

Revisiting scope of practice (SOP) policies for nurse practitioners (NPs) is necessary in the evolving primary care environment with goals to provide timely access, improve quality, and contain cost. This study utilized qualitative descriptive design to investigate NP roles and responsibilities as primary care providers (PCPs) in Massachusetts and their perceptions about barriers and facilitators to their SOP. Through purposive sampling, 23 NPs were recruited and they participated in group and individual interviews in spring 2011.The interviews were audio recorded and transcribed. Data were analyzed using Atlas.ti 6.0 software, and content analysis was applied. In addition to NP roles and responsibilities, three themes affecting NP SOP were: regulatory environment; comprehension of NP role; and work environment. NPs take on similar responsibilities as physicians to deliver primary care services; however, the regulatory environment and billing practices, lack of comprehension of the NP role, and challenging work environments limit successful NP practice.

Older adults’ home- and community-based care service use and residential transitions: a longitudinal study

BackgroundAs Home-and Community-Based Services (HCBS), such as skilled nursing services or personal care services, have become increasingly available, it has become clear that older adults transit through different residential statuses over time. Older adults may transit through different residential statuses as the various services meet their needs. The purpose of this exploratory study was to better understand the interplay between community-dwelling older adults’ use of home- and community-based services and their residential transitions.MethodsThe study compared HCBS service-use patterns and residential transitions of 3,085 older adults from the Second Longitudinal Study of Aging. Based on older adults’ residential status at the three follow-up interviews, four residential transitions were tracked: (1) Community-Community-Community (CCC: Resided in community during the entire study period); (2) Community-Institution-Community (CIC: Resided in community at T1, had lived in an institution at some time between T1 and T2, then had returned to community by T3); (3) Community-Community-Institution (CCI: Resided in community between at T1, and betweenT1 and T2, including at T2, but had used institutional services between T2 and T3); (4) Community-Institution-Institution (CII: Resided in community at T1 but in an institution at some time between T1 and T2, and at some time between T2 and T3.).ResultsOlder adults’ use of nondiscretionary and discretionary services differed significantly among the four groups, and the patterns of HCBS use among these groups were also different. Older adults’ use of nondiscretionary services, such as skilled nursing care, may help them to return to communities from institutions. Personal care services (PCS) and senior center services may be the key to either support elders to stay in communities longer or help elders to return to their communities from institutions. Different combinations of PCS with other services, such as senior center services or meal services, were associated with different directions in residential transition, such as CIC and CII respectively.ConclusionsOlder adults’ differing HCBS use patterns may be the key to explaining older adults’ transitions. Attention to older adults’ HCBS use patterns is recommended for future practice. However, this was an exploratory study and the analyses cannot establish causal relationships.

Nurse practitioners as attending providers for injured workers: evaluating the effect of role expansion on disability and costs.

Background:A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers’ compensation system was implemented on July 1, 2004. This legislation authorized NPs to independently perform most functions of an attending physician. Objective:The purpose of this study was to assess the impact of this legislation by examining medical costs and disability outcomes for injured workers in the care of NPs benchmarked against those in the care of primary care physicians (PCPs). Research Design:This observational study compared NPs and PCPs in the role of attending provider based on the medical costs and disability outcomes of injured workers in their care. Comparisons controlled for sociodemographics, geographic location, injury, employment, and provider characteristics. Data Source:The Washington State Department of Labor and Industries provided claim and medical billing data for 29,949 injured workers who had an accident report filed by an NP or PCP between July 1, 2004 and June 30, 2005. Data were collected through June 30, 2006. Results:NPs were more likely than PCPs to be located in rural areas and counties with high unemployment. The distributions of injury type and severity/complexity indicators were similar across provider types. The likelihood of any time loss was lower for NP claims, but duration of lost work time and medical costs did not significantly differ by provider type. Conclusions:Attending provider type is not a significant predictor of disability or medical costs for injured workers in Washington State.

Increasing Minority Representation in the Health Professions.

Research indicates that health disparities may be reduced by increasing the number of ethnic minorities working in health occupations. Establishing health career pathway programs for immigrant and ethnic minority students is one way to address this problem. One such program, Cross-Cultural Education in Public Health (CCEPH), was developed, implemented, and evaluated to determine whether participants expressed greater interest in pursuing health care careers after program completion. A sample of 72 immigrant students in two high schools participated in the program, which was based on Banduras theory of self-efficacy. Data were gathered using pre- and postprogram surveys that measured academic self-efficacy and career consideration. Results for academic efficacy were not statistically significant, but interest level in health care careers rose substantially. Although further research needs to be conducted to determine whether such programs increase self-efficacy, programs such as CCEPH can increase the consideration of health careers among immigrant and ethnic minority students.

Nurse practitioners as attending providers for workers with uncomplicated back injuries: using administrative data to evaluate quality and process of care.

Objective: The objectives of this study were 1) to identify quality and process of care indicators available in administrative workers’ compensation data and to document their association with work disability outcomes, and 2) to use these indicators to assess whether nurse practitioners (NPs), recently authorized to serve as attending providers for injured workers in Washington State, performed differently than did primary care physicians (PCPs). Methods: Quality and process of care indicators for NP and PCP back injury claims from Washington State were compared using direct standardization and logistic regression. Results: This study found little evidence of differences between NP and PCP claims in case mix or quality of care. Conclusions: The process of care indicators that we identified were highly associated with the duration of work disability and have potential for further development to assess and promote quality improvement.

Nurse practitioners as primary care providers: Creating favorable practice environments in New York State and Massachusetts

BACKGROUND Policy makers, health care organizations, and health professionals are calling for the expansion of the nurse practitioner (NP) workforce in primary care to ensure access to high-quality, cost-effective care. However, to date, little is known about NP practice environments in primary care settings and how they may affect the expansion of this workforce and their practice. PURPOSES The aims of this study were to investigate NP practice environments in two states, Massachusetts (MA) and New York State (NY), and determine the impact of state and organization on NP practice environment. METHODOLOGY A cross-sectional survey design was used. Practice environments were measured using the Nurse Practitioner Primary Care Organizational Climate Questionnaire in terms of NP-physician relations, NP-administration relations, support, NP role comprehension, and NP independent practice. In MA, 291 NPs were recruited from the Massachusetts Provider Database through mail surveys. In NY, 278 NPs were recruited from the NY Nurse Practitioner Association membership list through online surveys. Data were collected from May through September 2012. Descriptive statistics were computed. Multivariate analysis of variance was conducted to investigate the effect of state and organization type on NP practice environments. FINDINGS Nurse practitioners reported favorable relationships with physicians, deficiencies in their relationships with administrators, and lack of support. Nurse practitioners from MA reported better practice environments. Nurse practitioners from hospital-affiliated practices perceived poorer practice environments than did NPs practicing in physician offices and community health centers. PRACTICE IMPLICATIONS Optimal working relations with physicians and administration, access to resources, and clarity in NP role are necessary to create practice environments where NPs can function effectively as primary care providers.

Public health infrastructure system change: outcomes from the turning point initiative.

The Robert Wood Johnson and W.K. Kellogg Foundations created the Turning Point initiative to transform and strengthen the public health infrastructure. This study examined 135 public health system changes for their links to multiple sector collaborative engagement, essential public health services, health outcomes, and infrastructure building strategies. An on-line documentation system developed by the University of Kansas was used to record and analyze these linkages. The results showed that each state accomplished notable system changes; the majority involved more than one sector and primarily related to increasing local public health system capacity and organizational change.