A new kind of gatekeeper: The increasing prevalence of Advanced Practice Nurses as case managers in US hospitals

Abstract

Case management is a representation of managed care, cost-containment organizational practices in healthcare, where managed care and its constitutive parts are situated against physician autonomy and decision-making. As a professional field, case management has evolved considerably, with the role recently taken up increasingly by Advanced Practice Nurses in various health care settings. We look at this evolution of a relatively new work task for Advanced Practice Nurses using a countervailing powers perspective, which allows us to move beyond discussions of case management effectiveness and best practices, and draw connections to trends in the social organization of healthcare, especially hospitals. We evaluated organizational (hospital-level) and environmental (county and state-level) characteristics associated with hospitals’ use of Advanced Practice Nurses as case managers, using data from U.S. community acute care hospitals for 2016–2018, collected from three data sources: American Hospital Association annual survey (AHA), Centers for Medicare and Medicaid Services (CMS), and Area Resource File. Among organizational characteristics, we found that hospitals that are a part of established Accountable Care Organizations (OR = 2.55, p = 0.009; 95% CI = 1.26–5.14) and those that serve higher acuity patients, as indicated by possessing a higher Case Mix Index (OR = 1.32, p = 0.001; 95% CI = 1.13–1.55), were more likely to use Advanced Practice Nurses as case managers. Among environmental characteristics, having higher local Advanced Practice Nurses concentrations (OR = 1.24, p < 0.001; 95% CI = 1.11–1.39) was associated with hospital Advanced Practice Nurses case management service provision. Beyond the health impacts of Covid-19, its associated recession is placing families, governments and insurers under unprecedented financial stress. Governments and insurers alike are looking to reduce costs anywhere possible. This will inevitably result in increasing amounts of managed care, and decreasing reimbursements to hospitals, likely resulting in higher demand for APRN patient navigators.

Primary Healthcare Case Management Nurses and Assistance Provided to Chronic Patients: A Narrative Review

“…CMNs are nurses with advanced practice nursing (APN) competencies, which improve chronic patients’ health [ 31 ]. This is in line with other studies not discussed in this review, where CMNs have been considered as effective and efficient APNs [ 22 , 23 ]; in addition, it has been stated that APNs possess specialised knowledge, as well as skills in complex decision making and clinical competencies [ 21 ].…”

“…CM has evolved favourably and been considered as AP, showing a reduction in costs and improvements in care management [ 22 , 23 ]. In the Primary Health Care Strategy of the Andalusian 2020–2022 Strategic Plan, it was proposed to implement proactive follow-ups of complex chronic patients, prioritising the assistance provided to people with heart failure and Chronic Obstructive Pulmonary Disease (COPD) by the means of instruments that ease continuity and proactive follow-ups by the primary healthcare (PHC) team.…”

Advanced practice nurse case managers improve efforts by US hospitals to address patient social needs

“…They are known to contribute to improved patient outcomes and satisfaction (Jennings et al., 2015), and there is growing belief that APNs will also produce similar outcomes in roles such as case management (Yip, 2021); APNs are highly capable professionals that could provide relief where hospitals are seeing patients readmitted for things out of their immediate control. The use of APN case managers is growing, and understanding more about their emerging roles is of interest to many hospital stakeholders and policymakers, both in the United States and internationally (Feyereisen, McConnell, et al., 2021; Feyereisen, Puro, et al., 2021). By examining over 2000 recent hospitals from the 2021 American Hospital Association (AHA) survey, we are able to add to the growing literature concerned with hospital‐based social prescribing and partnership strategies.…”

Physician dominance in the 21st century: Examining the rise of non‐physician autonomy through prevailing theoretical lenses

“…Nursing illustrates this trend. Increasing numbers of Advanced Practice Nurses (APNs), such as nurse practitioners (NPs), nurse anaesthetists (CRNAs), nurse midwives (NMWs) and clinical nurse specialists (CNSs), have in many cases taken on roles traditionally filled by physicians (Feyereisen & Goodrick, 2020; Feyereisen et al, 2021; Needleman & Minnick, 2009; Spetz et al, 2017). In the United States, APN autonomy varies based on state‐level laws.…”