The perfect storm: managed care, aging adults, and a nursing shortage.

The many issues managed care poses for providers and health networks are crystallized in the moral problems occasioned by its shifting of the financial risks of care from the insurer to the provider. Yet, of 257 data-based studies of nursing care quality identified, 135 investigated a process-outcome link but only 17 met study inclusion criteria. The literature provides evidence that the quality of nursing care processes affects health-related patient outcomes during and after hospitalization. Thus, California became the first state to mandate nurse staffing ratios on all units in 1997. All the while labor shortages, introduction of new technology, and the increased acuity of the inpatient population have contributed to the rising costs of hospital-based care. Another notable contribution to the financial and clinical pressures hospitals feel is the overall increased consumer demand for services: The aging of America's population portends an even greater demand for healthcare services. This situation will only grow worse as the demand generated by the growing gerontocracy increasingly outstrips an affordable supply of safe care. Little time and few resources are available for what we might all agree would be the desired level of comprehensive and coordinated care. What this means for patients is that they experience episodic acute care that is delivered in "spurts." No matter what actions are taken - or more likely not taken - to reform the Medicare program, the future holds shrinking reimbursement for hospitals, with a concurrent demand for investments in response to costly regulatory requirements, technologies, and other capital expenditures to accommodate the increasing demand for services generated by the growing numbers of politically active seniors who insist on the entitlements promised to them - and the quality of service they believe is their right. This is the Perfect Storm....