Getting to universal coverage with better safety-net programs for the uninsured

Safety-net providers in some US communities have increasingly embraced coordinated care models

Safety-net organizations, which provide health services to uninsured and low-income people, increasingly are looking for ways to coordinate services among providers to improve access to and quality of care and to reduce costs. In this analysis, a part of the Community Tracking Study, we examined trends in safety-net coordination activities from 2000 to 2010 within twelve communities in the United States and found a notable increase in such activities. Six of the twelve communities had made formal efforts to link uninsured people to medical homes and coordinate care with specialists in 2010, compared to only two communities in 2000. We also identified key attributes of safety-net coordinated care systems, such as reliance on a medical home for meeting patients' primary care needs, and lingering challenges to safety-net integration, such as competition among hospitals and community health centers for Medicaid patients.

Impact of nurse staffing mandates on safety-net hospitals: lessons from California

CONTEXT

California is the first and only state to implement a patient-to-nurse ratio mandate for hospitals. Increasing nurse staffing is an important organizational intervention for improving patient outcomes. Evidence suggests that staffing improved in California hospitals after the mandate was enacted, but the outcome for hospitals bearing a disproportionate share of uncompensated care-safety-net hospitals-remains unclear. One concern was that California's mandate would burden safety-net hospitals without improving staffing or that hospitals would reduce their skill mix, that is, the proportion of registered nurses of all nursing staff. We examined the differential effect of California's staffing mandate on safety-net and non-safety-net hospitals.

METHODS

We used a time-series design with Annual Hospital Disclosure data files from the California Office of Statewide Health Planning and Development (OSHPD) for the years 1998 to 2007 to assess differences in the effect of California's mandate on staffing outcomes in safety-net and non-safety-net hospitals.

FINDINGS

The mandate resulted in significant staffing improvements, on average nearly a full patient per nurse fewer (-0.98) for all California hospitals. The greatest effect was in those hospitals with the lowest staffing levels at the outset, both safety-net and non-safety-net hospitals, as the legislation intended. The mandate led to significantly improved staffing levels for safety-net hospitals, although there was a small but significant difference in the effect on staffing levels of safety-net and non-safety-net hospitals. Regarding skill mix, a marginally higher proportion of registered nurses was seen in non-safety-net hospitals following the mandate, while the skill mix remained essentially unchanged for safety-net hospitals. The difference between the two groups of hospitals was not significant.

CONCLUSIONS

California's mandate improved staffing for all hospitals, including safety-net hospitals. Furthermore, improvement did not come at the cost of a reduced skill mix, as was feared. Alternative and more targeted designs, however, might yield further improvement for safety-net hospitals and reduce potential disparities in the staffing and skill mix of safety-net and non-safety-net hospitals.