Journal of Healthcare Management - September/October 2016 - 372

J o u r n al of H ealt H care M anageMent 61:5 S epte Mber /o ctober 2016 External Constraints and Opportunities CEOs from CHCs with nurses on staff reported that they were almost all RNs with associate degrees and LPNs; only one CHC employed a nurse-who served in a management role-with a bachelor of science in nursing (BSN). The high prevalence of LPNs at some CHCs was surprising because the Bureau of Labor Statistics (BLS) (2015) reports that LPNs work primarily in long-term care facilities. In addition, because the UDS does not allow differentiation between RNs and LPNs, quantitative data about their participation in CHCs are lacking. Sites that employed LPNs as the main support staff often had community colleges nearby with LPN programs. Participants whose CHCs were located near hospitals noted the difficulty in competing with them for RNs given the higher wages and prestige of hospitals. Interestingly, some participants said that hospitals' increased interest in hiring nurses with BSN degrees (Institute of Medicine, 2010) benefited their CHCs because it increased their access to nurses with associate degrees. In particular, a North Dakota CEO stated that he was able to hire nurses who had entered associate degree programs hoping to work at the local hospital, but had not found jobs. CEOs also commented on the way in which wages affected their choices. The CEO of a rural Tennessee CHC that mostly employed MAs noted, "It's really a funding issue. . . . We pay an MA $25,000 to $30,000 a year and a nurse 40, 50, or 60 [thousand]." Similarly, in Alaska, a CEO indicated that he hired RNs only for supervisory roles because of their relatively high salary. Other CEOs described LPNs as a cost-effective midpoint between MAs and RNs. By contrast, in New Hampshire and Virginia, nurses' wages in outpatient settings were significantly lower than the national average (BLS, 2014). One CEO acknowledged that RNs' relatively low wages were what made it possible to hire them. The New Hampshire CEO also stated that hiring nurses for certain services was possible because two local commercial insurance carriers reimbursed the CHC. CEOs also considered the SOP of LPNs and MAs in choosing between them. While they reported that MAs took vital signs, performed phlebotomy, and acted as scribes entering data into the EHRs, many CEOs indicated that MAs were prohibited from administering injections or calling in prescriptions; thus, LPNs were preferable when available. Conversely, in Alaska, LPNs' limited SOP led CEOs to favor MAs. More than half of the CHCs in our sample had received PCMH recognition or were working toward it, and some CEOs reported that this influenced their hiring decisions. The Virginia CEO whose CHC had a high proportion of nurses indicated that the PCMH was the reason she hired MAs for the first time: "I would not have hired an MA had it not been for the PCMH recommendation to have MAs on staff," she said. Other CEOs reported hiring MAs for the purpose of managing databases or disease registries, and some large CHCs hired RNs to provide quality improvement oversight. 372

Table of Contents for the Digital Edition of Journal of Healthcare Management - September/October 2016