Caroline E. Stephens

Caroline E. Stephens, PhD, GNP, FAAN

Dr. Stephens is an Associate Professor and the Helen Lowe Bamberger Colby Presidential Endowed Chair in Gerontological Nursing. Informed by nearly 20 years of clinical experience as a Gerontological Nurse Practitioner and Geropsychiatric Advanced Practice Nurse, including consulting in over 100 nursing homes in 3 states, her program of research focuses on vulnerable populations at high risk for poor care transitions, particularly in the post-acute/long-term care setting. Key findings from her national population-based studies reveal that ED use by vulnerable nursing home residents is not only common, but frequently preventable. Her mixed-methods research has highlighted how suboptimal communication between hospitals, nursing homes and families, as well as poor access to appropriate and timely palliative care, contribute to frequent hospital transfers by our most high risk older adults. Additional findings published in JAMA IM reveal that the majority of nursing home residents are eligible for palliative care, but do not receive it. Moreover, families feel unprepared as advocates and knowledge gaps often lead them to ineffectively or inappropriately advocate for care. Her current extramurally-funded program of research is focused on developing and testing the Improving Palliative Care Access Through Technology (ImPAcTT) intervention in the long term care setting.

Selected Publications

Journal Article

  1. Halifax E Bui NM Hunt LJ Stephens CE (02/01/2020). Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care, 825859720904802. (Read full article)
  2. Oh A Patel K Boscardin WJ Max W Stephens C Ritchie CS Smith AK (01/01/2020). Social Support and Patterns of Institutionalization Among Older Adults: A Longitudinal Study. J Am Geriatr Soc, 67, 2622-2627. (Read full article)
  3. Hunt LJ Stephens CE Smith AK (11/11/2019). Palliative Care in the Nursing Home-Shifting Paradigms. JAMA Intern Med, 1-2. (Read full article)
  4. Coombs LA Stephens C (11/01/2019). Identifying the Contribution of Nurse Practitioners in the Care of Older Adults With Cancer. Oncol Nurs Forum, 46(3), 277-282. (Read full article)
  5. Bui N (10/01/2019). Understanding Nursing Home Staff Attitudes Towards Death & Dying. Am J Nurs.
  6. Coombs LA Max W Kolevska T Tonner C Stephens C (07/01/2019). Nurse Practitioners and Physician Assistants: An Underestimated Workforce for Older Adults with Cancer. J Am Geriatr Soc, 67(7), 1489-1494. (Read full article)
  7. Linnen DT Escobar GJ Hu X Scruth E Liu V Stephens C (06/01/2019). Statistical Modeling and Aggregate-Weighted Scoring Systems in Prediction of Mortality and ICU Transfer: A Systematic Review. J Hosp Med, 14, 161-169. (Read full article)
  8. Stephens CE Halifax E David D Bui N Lee SJ Shim J Ritchie CS (04/21/2019). "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res, 29, 157-168. (Read full article)
  9. Hunt LJ Ritchie CS Cataldo JK Patel K Stephens CE Smith AK (12/01/2018). Pain and Emergency Department Use in the Last Month of Life Among Older Adults With Dementia. J Pain Symptom Manage, 56, 871-877.e7. (Read full article)
  10. Hunt LJ Coombs LA Stephens CE (09/01/2018). Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review. J Gerontol Nurs, 44(3), 23-30. (Read full article)
  11. Stephens CE Evans LK Bradway C Buckwalter K (04/01/2018). Challenges in Aging, Dementia, and Mental Health: New Knowledge and Energy to Inform Solutions. J Am Geriatr Soc, 66 Suppl 1, S1-S3. (Read full article)
  12. Linnen DT Kornak J Stephens C (03/28/2018). The Rural Inpatient Mortality Study: Does Urban-Rural County Classification Predict Hospital Mortality in California? Perm J, 22, 17-078. (Read full article)
  13. Stephens CE Hunt LJ Bui N Halifax E Ritchie CS Lee SJ (11/20/2017). Palliative Care Eligibility, Symptom Burden, and Quality-of-Life Ratings in Nursing Home Residents. JAMA Intern Med, 178, 141-142. (Read full article)
  14. Harris M Buron B Stephens C (09/09/2017). Embracing the challenges in graduate geropsychiatric nursing education: Findings from a national survey. 34, 221-225. (Read full article)
  15. Hunt LJ Covinsky KE Yaffe K Stephens CE Miao Y Boscardin WJ Smith AK (11/01/2015). Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study. J Am Geriatr Soc, 63, 1503-11. (Read full article)
  16. Stephens C Halifax E Bui N Lee SJ Harrington C Shim J Ritchie C (09/01/2015). Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life. Curr Gerontol Geriatr Res, 2015, 893062. (Read full article)
  17. Stephens CE Harris M Buron B (01/01/2015). The Current State of U.S. Geropsychiatric Graduate Nursing Education: Results of the National Geropsychiatric Graduate Nursing Education Survey. J Am Psychiatr Nurses Assoc, 21(6), 385-94. (Read full article)
  18. Newman J (01/01/2015). Advance Care Planning: A Community-Based Initiative in San Francisco.
  19. Stephens C (03/20/2014). Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: A national study. BMC Geriatr, 14. (Read full article)
  20. Stephens C (01/01/2014). The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations. 10, 835-843. (Read full article)
  21. Brownell J (10/28/2013). Trends in Emergency Department Visits for Ambulatory Care Sensitive Conditions by Elderly Nursing Home Residents, 2001-2009.
  22. Stephens C (04/06/2013). Transitional Care Challenges of Rehospitalized Veterans: Listening to Patients and their Providers. Popul Health Manag.
  23. Stephens C (06/01/2012). Emergency Department use by nursing home residents: Effect of severity of cognitive impairment. 52, 383-393. (Read full article)
  24. Naylor MD (01/2007). Care Coordination for Cognitively Impaired Older Adults and Their Caregivers . Home Health Care Serv Q, 26(4), 57-78.
  25. Naylor MD (01/2005). Cognitively Impaired Older Adults: From Hospital to Home. Am J Nurs, 105(2), 40-49.