Caroline Stephens, RN, PhD, GNP

Associate Professor
Campus Phone
Address Postal

2 Koret Way, Rm 531E
UCSF Box 0608
San Francisco, CA 94143
United States

My program of research focuses on vulnerable populations at high risk for poor care transitions, particularly in the long term care setting. Using national CMS claims and resident assessment data, I recently completed a series of studies examining key factors associated with Emergency Department (ED) use by high risk nursing home residents, such as those with cognitive impairment, a history of falls and feeding tubes. While much of my work to date has involved large data set analyses, I am currently looking at innovative ways we can use emerging health technologies to promote greater interdisciplinary collaborative work processes across care settings and more actively engage nursing home residents, families, nursing home staff and EDs to reduce unnecessary acute care transfers and promote better care coordination.

Clinically, I am a Gerontological Nurse Practitioner and Geropsychiatric Advanced Practice Nurse, and I have cared for frail older adults across the care continuum, including the provision of geropsychiatric consultations in over 100 nursing homes in 3 states. I still maintain a geropsychiatric faculty practice in the nursing home setting.

From a teaching perspective, I am passionate about, and locally and nationally involved in, figuring out innovative ways to infuse more gerontological and geropsychiatric content into the generalist APN curriculum and across disciplines.
Clinical Translational Sciences Institute (CTSI) KL2 Scholar, UCSF, 2013-2018
National Veteran's Administration Quality Scholar (VAQS), San Francisco VA Medical Center, 2010-2012
John A. Hartford Foundation/Atlantic Philanthropies Claire M. Fagin Fellow, UCSF, 2010-2012
Sigma Theta Tau International Nursing Honors Society Research Award, Alpha Eta Chapter - UCSF, 2010
9th Annual UCSF Outstanding Health Policy Paper Award, UCSF, 2008
John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar, UCSF, 2007-2009
Cota Robles Fellow, UCSF, 2006-2007
University of Pennsylvania Dean's Award, University of Pennsylvania, 2002
Sigma Theta Tau, International Nursing Honors Society, Xi & Alpha Eta Chapters, 1999
University of Pennsylvania Nightingale Award, University of Pennsylvania, 1999
BS, Biological Psychology with Minor in Human Development & Aging, 1995 - College of Letters & Sciences, University of California, Davis

The Current State of U.S. Geropsychiatric Graduate Nursing Education: Results of the National Geropsychiatric Graduate Nursing Education Survey.


Advanced Practice Registered Nurses (APRNs) must be prepared to care for the rapidly increasing numbers of older adults with mental health needs. All 363 graduate nursing programs in the United States were surveyed regarding the nature and extent of geropsychiatric nursing (GPN) content across program curricula and their perceptions of the influence that the APRN Consensus Model has exerted on preparing the next generation of APRNs to meet the growing needs of the older adult population. Of the 202 schools responding, 138 reported GPN content in one or more clinical programs, with the majority of content in non-PMHNP programs. Only 17 schools reported offering a GPN program, track, or minor. The majority of schools (n = 169) perceived that they were adequately well-prepared to meet the APRN Consensus Model's guidelines regarding inclusion of aging-related didactic and clinical educational experiences in all APRN education programs; nearly two thirds (n = 132) perceived a moderate to significant influence of the Consensus Model on institutional infusion of GPN into curricula. Compared with a similar survey 10 years ago, there was little change in the proportion of schools reporting GPN in clinical programs and few schools provide GPN programs, tracks, or minors. Implications for nursing education and practice are discussed.

Provider Perspectives on the Influence of Family on Nursing Home Resident Transfers to the Emergency Department: Crises at the End of Life.


Background. Nursing home (NH) residents often experience burdensome and unnecessary care transitions, especially towards the end of life. This paper explores provider perspectives on the role that families play in the decision to transfer NH residents to the emergency department (ED). Methods. Multiple stakeholder focus groups (n = 35 participants) were conducted with NH nurses, NH physicians, nurse practitioners, physician assistants, NH administrators, ED nurses, ED physicians, and a hospitalist. Stakeholders described experiences and challenges with NH resident transfers to the ED. Focus group interviews were recorded and transcribed verbatim. Transcripts and field notes were analyzed using a Grounded Theory approach. Findings. Providers perceive that families often play a significant role in ED transfer decisions as they frequently react to a resident change of condition as a crisis. This sense of crisis is driven by 4 main influences: insecurities with NH care; families being unprepared for end of life; absent/inadequate advance care planning; and lack of communication and agreement within families regarding goals of care. Conclusions. Suboptimal communication and lack of access to appropriate and timely palliative care support and expertise in the NH setting may contribute to frequent ED transfers.

Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study.



To report prevalence, correlates, and medication management of pain in community-dwelling older adults with dementia.




In-person interviews with self- or proxy respondents living in private residences or non-nursing home residential care settings.


Nationally representative sample of community-dwelling Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study 2011 wave.


Dementia status was determined using a modified previously validated algorithm. Participants were asked whether they had had bothersome and activity-limiting pain over the past month. A multivariable Poisson regression model was used to determine the relationship between bothersome pain and sociodemographic and clinical characteristics.


Of the 7,609 participants with complete data on cognitive function, 802 had dementia (67.2% aged ≥80, 65.0% female, 67.9% white, 49.7% proxy response, 32.0% lived alone, 18.8% lived in residential care); 670 (63.5%) participants with dementia experienced bothersome pain, and 347 (43.3%) had pain that limited activities. These rates were significantly higher than in a propensity score-matched cohort without dementia (54.5% bothersome pain, P


Community-living older adults with dementia are at high risk of having pain. Creative interventions and programs are needed to manage pain adequately in this vulnerable population.

The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations.



Little is known about the relationship of cognitive impairment (CI) in nursing home (NH) residents and their use of emergency department (ED) and subsequent hospital services.


We analyzed 2006 Medicare claims and resident assessment data for 112,412 Medicare beneficiaries aged >65 years residing in US nursing facilities. We estimated the effect of resident characteristics and severity of CI on rates of total ED visits per year, then estimated the odds of hospitalization after ED evaluation.


Mild CI predicted higher rates of ED visits relative to no CI, and ED visit rates decreased as severity of CI increased. In unadjusted models, mild CI and very severe CI predicted higher odds of hospitalization after ED evaluation; however, after adjusting for other factors, severity of CI was not significant.


Higher rates of ED visits among those with mild CI may represent a unique marker in the presentation of acute illness and warrant further investigation.

Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study.



Numerous studies indicate that the use of feeding tubes (FT) in persons with advanced cognitive impairment (CI) does not improve clinical outcomes or survival, and results in higher rates of hospitalization and emergency department (ED) visits. It is not clear, however, whether such risk varies by resident level of CI and whether these ED visits and hospitalizations are potentially preventable. The objective of this study was to determine the rates of ED visits, hospitalizations and potentially preventable ambulatory care sensitive (ACS) ED visits and ACS hospitalizations for long-stay NH residents with FTs at differing levels of CI.


We linked Centers for Medicare and Medicaid Services inpatient & outpatient administrative claims and beneficiary eligibility data with Minimum Data Set (MDS) resident assessment data for nursing home residents with feeding tubes in a 5% random sample of Medicare beneficiaries residing in US nursing facilities in 2006 (n = 3479). Severity of CI was measured using the Cognitive Performance Scale (CPS) and categorized into 4 groups: None/Mild (CPS = 0-1, MMSE = 22-25), Moderate (CPS = 2-3, MMSE = 15-19), Severe (CPS = 4-5, MMSE = 5-7) and Very Severe (CPS = 6, MMSE = 0-4). ED visits, hospitalizations, ACS ED visits and ACS hospitalizations were ascertained from inpatient and outpatient administrative claims. We estimated the risk ratio of each outcome by CI level using over-dispersed Poisson models accounting for potential confounding factors.


Twenty-nine percent of our cohort was considered "comatose" and "without any discernible consciousness", suggesting that over 20,000 NH residents in the US with feeding tubes are non-interactive. Approximately 25% of NH residents with FTs required an ED visit or hospitalization, with 44% of hospitalizations and 24% of ED visits being potentially preventable or for an ACS condition. Severity of CI had a significant effect on rates of ACS ED visits, but little effect on ACS hospitalizations.


ED visits and hospitalizations are common in cognitively impaired tube-fed nursing home residents and a substantial proportion of ED visits and hospitalizations are potentially preventable due to ACS conditions.

Transitional care challenges of rehospitalized veterans: listening to patients and providers.


Readmissions to the hospital are common and costly, often resulting from poor care coordination. Despite increased attention given to improving the quality and safety of care transitions, little is known about patient and provider perspectives of the transitional care needs of rehospitalized Veterans. As part of a larger quality improvement initiative to reduce hospital readmissions, the authors conducted semi-structured interviews with 25 patients and 14 of their interdisciplinary health care providers to better understand their perspectives of the transitional care needs and challenges faced by rehospitalized Veterans. Patients identified 3 common themes that led to rehospitalization: (1) knowledge gaps and deferred power; (2) difficulties navigating the health care system; and (3) complex psychiatric and social needs. Providers identified different themes that led to rehospitalization: (1) substance abuse and mental illness; (2) lack of social or financial support and homelessness; (3) premature discharge and poor communication; and (4) nonadherence with follow-up. Results underscore that rehospitalized Veterans have a complex overlapping profile of real and perceived physical, mental, and social needs. A paradigm of disempowerment and deferred responsibility appears to exist between patients and providers that contributes to ineffective care transitions, resulting in readmissions. These results highlight the cultural constraints on systems of care and suggest that process improvements should focus on increasing the sense of partnership between patients and providers, while simultaneously creating a culture of empowerment, ownership, and engagement, to achieve success in reducing hospital readmissions.

Emergency department use by nursing home residents: effect of severity of cognitive impairment.



To examine the 1-year prevalence and risk of emergency department (ED) use and ambulatory care-sensitive (ACS) ED use by nursing home (NH) residents with different levels of severity of cognitive impairment (CI).


We used multinomial logistic regression to estimate the effect of CI severity on the odds of any ED visit and any ACS ED visit in a 2006 national random sample of NH residents, controlling for predisposing, enabling, and need characteristics.


Of 132,753 NH residents, 62% had at least one ED visit and approximately 24% had at least one ACS ED visit in 2006. The probability of any ED visit or any ACS ED visit varied with the severity of resident CI. Residents with mild CI had up to 15% higher odds of any ED or any ACS ED visit and those with more moderate CI had 9% higher odds of an ACS ED visit compared with those without CI. The probability of any ED visit was negatively associated with advanced dementia (adjusted odds ratio = 0.60; 95% CI = 0.55-0.65).


Earlier identification of persons with mild CI may facilitate patient, family, and staff education, as well as advanced care planning to reduce ACS ED visits. Both ACS ED use and hospitalizations, adjusted for case mix, should be used as quality indicators to help ensure greater accountability for high-quality NH care and more appropriate utilization of ED resources.

Care coordination for cognitively impaired older adults and their caregivers.


Dementia and delirium, the most common causes of cognitive impairment (CI) among hospitalized older adults, are associated with higher mortality rates, increased morbidity and higher health care costs. A growing body of science suggests that these older adults and their caregivers are particularly vulnerable to systems of care that either do not recognize or meet their needs. The consequences can be devastating for these older adults and add to the burden of hospital staff and caregivers, especially during the transition from hospital to home. Unfortunately, little evidence exists to guide optimal care of this patient group. Available research findings suggest that hospitalized cognitively impaired elders may benefit from interventions aimed at improving care management of both CI and co-morbid conditions but the exact nature and intensity of interventions needed are not known. This article will explore the need for improved transitional care for this vulnerable population and their caregivers.

Nursing Homes
Homes For The Aged
Emergency Service, Hospital
Cognition Disorders