Ulrike Muench

Recent Department of Education actions implementing graduate loan limits under the One Big Beautiful Bill Act excluded nursing from “professional program” designation, creating a policy misalignment that threatens the advanced nursing workforce. Using data from the 2022 National Sample Survey of Registered Nurses, we demonstrate that educational debt is a structural feature of nursing careers and a barrier to progression into advanced practice and faculty roles. Debt accumulates across nursing careers and disproportionately affects nurses from historically marginalized racial and ethnic groups, nurses with dependents, and those advancing through associate-degree pathways. We argue that excluding nursing from professional program loan classification misaligns federal borrowing policy with the cumulative structure of nursing education and threatens equitable access to advanced training and the pipelines essential to health system capacity.

Demand for home health is growing. Registered and licensed practical/vocational nurses (RNs and LPN/LVNs) are integral to the provision of home health services, but a limited body of evidence suggests that the workforce is unstable and possibly shrinking. We assessed RNs’ and LPN/LVNs’ transitions into and out of the home health sector using data from the Current Population Survey monthly files from January 2003 to June 2023. Specifically, we compared turnover from home health versus the hospital sector and assessed entry into home health from other health care and non–health care sectors. Turnover was consistently and significantly higher in the home health sector compared with the hospital sector. The predicted probability of nurses entering home health from any other sector hovered around or below 1%. High turnover combined with low home health entry raises concerns about home health nursing services nationwide.

This cross-sectional study assesses receipt of opioids and daily morphine milligram equivalents among nursing home residents from 2011 to 2022.

The growing aging population and rising prevalence of dementia are driving increased demand for long‐term care services and supports in the United States. People with dementia require substantial support and care, often from direct care workers in private homes, assisted living communities, and nursing homes. Despite their crucial role, these workers receive highly variable training, particularly in dementia care, and face significant work‐related challenges including stress, injury, and burnout. The National Dementia Workforce Study (NDWS), sponsored by the National Institute on Aging, was designed to include large‐scale, nationally representative annual surveys of staff and administrators providing care to individuals with dementia in home care, assisted living, and nursing homes, and of community clinicians practicing across settings. NDWS will capture workforce demographics, training adequacy, job satisfaction, and their impact on dementia care quality. This report describes NDWS's rigorous process for questionnaire design for the initial wave of home care, assisted living, and nursing home surveys. Our survey development methods integrated literature reviews, validated questionnaire items, expert consultations, and cognitive interviews to ensure instrument reliability and validity. Resulting survey data will be available to researchers seeking to examine workforce conditions, training, and worker knowledge, and their impact on care for people with dementia. NDWS infrastructure will also allow researchers to link survey responses with administrative and medical claims data to examine how workforce dynamics and organizational factors are associated with outcomes for people with dementia over time, enabling insights into policies to improve dementia care training, workforce retention, and care delivery.

Improving access to midwifery care has been identified as a strategy to address shortages of reproductive health clinicians and ensure person-centered, equitable care. This article describes findings from a new survey of licensed midwives (LMs) in California, who enter the profession without a nursing background. The data offer new insights into LMs’ demographics, training, client population, and practice experiences. LMs predominantly have their own practices, typically working with another midwife and/or an assistant or student, and have relatively small numbers of clients each year. Most of the births they attend occur in homes and birth centers. Many LMs report a lack of understanding of and support for their expertise by physicians and hospitals. Despite these challenges, most LMs are satisfied with their careers. LMs contribute to person-centered care, offering alternatives to hospital birth and expanding access to the midwifery model of care.

People with dementia have complex medical, functional, and social needs and experience highly variable care quality and outcomes across the U.S. health care system. Community‐based physicians, nurse practitioners, and physician assistants serve critical roles in diagnosing and managing dementia, yet little is known about this workforce and factors contributing to variability in care. The National Dementia Workforce Study (NDWS), sponsored by the National Institute on Aging, is conducting large nationally representative surveys of health care workers who provide care to people with dementia in nursing homes, assisted living communities, home care, and community medical practices. In this report, we summarize the methods for one of those surveys, the NDWS Community Clinician Survey, which surveys community‐based physicians and advanced practice providers specializing in primary care, psychiatry, and neurology who provide clinical care to people with dementia. This survey captures comprehensive data on these clinicians, including demographics, training, and licensure; where and how they practice; their patient panels; processes of care for dementia diagnosis and management; and job factors influencing retention and turnover. These survey data can be linked with Medicare claims and other administrative data sources to allow for expansive research on this workforce and the care they provide. In turn, this will generate insights into modifiable factors that can be targeted to prepare, expand, and strengthen the clinical workforce to optimize care and meet demand for the growing population of people with dementia.

Nurse practitioners (NPs) are important providers of primary care to underserved populations, particularly in areas with lower physician supply. In 2023, California implemented new regulations aimed at improving access to care, especially primary care services, by providing a pathway for NPs to practice without formal supervision after 3 years of practice and without any physician relationship after 5 years of practice. This study used data from a representative survey of California-licensed NPs fielded in late 2022 to examine NPs' current practice and intentions following implementation of the new regulations. Results indicated notable differences in the characteristics of NPs who are considering establishing an independent primary care practice and who are considering changing their practice to serve more Medicaid enrollees at the advent of expanded scope of practice. The strong association between racial/ethnic identity and greater interest in practice change suggests that after the elimination of physician collaboration requirements, increasing the diversity of the NP workforce may be one of the most important strategies for increasing access to care for Californians and especially for people receiving Medicaid.

Background: Accurate and timely diagnosis of dementia is necessary to allow affected individuals to make informed decisions and access appropriate resources. When dementia goes undetected until a hospitalization or nursing home stay, this could reflect delayed diagnosis or misdiagnosis, and may reflect underlying disparities in healthcare access. Methods: In this retrospective cohort study, we used 2012–2020 Medicare claims and other administrative data to examine variation in setting of dementia diagnosis among fee‐for‐service Medicare beneficiaries with an initial claims‐based dementia diagnosis in 2016. We used multinomial logistic regression to evaluate the association of person and geographic factors with diagnosis location, and Cox proportional hazards regression to examine 4‐year survival relative to diagnosis location. Results: Among 754,204 Medicare beneficiaries newly diagnosed with dementia in 2016, 60.3% were diagnosed in the community, 17.2% in hospitals, and 22.5% in nursing homes. Adjusted 4‐year survival rates were significantly lower among those diagnosed in hospitals [−16.1 percentage points (95% CI: −17.0, −15.1)] and nursing homes [−16.8 percentage points (95% CI: −17.7, −15.9)], compared to those diagnosed in the community. Community‐diagnosed beneficiaries were more often female, younger, Asian or Pacific Islander, Native American or Alaskan Native, Hispanic, had fewer baseline hospitalizations and higher homecare use, and resided in wealthier ZIP codes. Rural beneficiaries were more likely to be diagnosed in hospitals. Conclusions: Many older adults are diagnosed with dementia in a hospital or nursing home. These individuals have significantly lower survival than those diagnosed in the community, which may indicate diagnosis during an acute illness or care transition, or at a later disease stage, all of which are suboptimal. These results highlight the need for improved dementia screening in the general population, particularly for individuals in rural areas and communities with higher social deprivation.

Background: Vulnerable older adults living with Alzheimer’s disease or Alzheimer’s disease and related dementia (AD/ADRD) and chronic pain generally receive fewer pain medications than individuals without AD/ADRD, especially in nursing homes. Little is known about pain management in older adults with AD/ADRD in the community. The aim of the study was to examine opioid prescribing patterns in individuals with chronic pain by levels of cognitive ability in ambulatory care. Methods: We used the Medical Expenditure Panel Survey (MEPS), years 2002–2017, and identified three levels of cognitive impairment: no cognitive impairment (NCI), individuals reporting cognitive impairment (CI) without an AD/ADRD diagnosis, and individuals with a diagnosis of AD/ADRD. We examined any receipt of an opioid prescription and the number of opioid prescriptions using a logistic and negative binomial regression adjusting for sociodemographic and health characteristics and stratifying by three types of chronic pain (any chronic pain, severe chronic pain, and chronic pain identified through ICD 9/10 chronic pain diagnoses). Results: Among people with any chronic pain, adjusted odds of receiving an opioid for people with CI (OR 1.41, 95% confidence interval 1.31–1.52) and AD/ADRD (OR 1.23, 95% confidence interval 1.04–1.45) were higher compared to NCI. Among people with chronic pain ICD 9/10 conditions, the odds of receiving an opioid were also higher for those with CI (OR 1.43, 95% confidence interval 1.34–1.56) and AD/ADRD (OR 1.48, 95% confidence interval 1.23–1.78) compared to NCI. Among those with severe chronic pain, people with CI were more likely to receive an opioid (OR 1.17, 95% confidence interval 1.07–1.27) relative to NCI (OR 0.89, 95% confidence interval 0.75–1.06). People with AD/ADRD experiencing severe chronic pain were not more likely to receive an opioid compared to the NCI group. Adjusted predicted counts of opioid prescriptions showed more opioids in CI and AD/ADRD in all chronic pain cohorts, with the largest numbers of opioid prescriptions in the severe chronic pain and ICD 9/10 diagnoses groups. Conclusions: The results suggest increased opioid use in people living with CI and AD/ADRD in the ambulatory care setting and potentially indicate that these individuals either require more analgesics or that opioids may be overprescribed. Further research is needed to examine pain management in this vulnerable population.