patient assignment means

• Type 2 Diabetes
• Heart Disease
• Digestive Health
• Multiple Sclerosis
• Diet & Nutrition
• Supplements
• Health Insurance
• Public Health
• Patient Rights
• Caregivers & Loved Ones
• End of Life Concerns
• Health News
• Thyroid Test Analyzer
• Doctor Discussion Guides
• Hemoglobin A1c Test Analyzer
• Lipid Test Analyzer
• Complete Blood Count (CBC) Analyzer
• What to Buy
• Editorial Process
• Meet Our Medical Expert Board

Medicare Assignment: Everything You Need to Know

Medicare assignment.

• Providers Accepting Assignment
• Providers Who Do Not
• Billing Options
• Assignment of Benefits
• How to Choose

Frequently Asked Questions

Medicare assignment is an agreement between Medicare and medical providers (doctors, hospitals, medical equipment suppliers, etc.) in which the provider agrees to accept Medicare’s fee schedule as payment in full when Medicare patients are treated.

This article will explain how Medicare assignment works, and what you need to know in order to ensure that you won’t receive unexpected bills.

fizkes / Getty Images

There are 35 million Americans who have Original Medicare. Medicare is a federal program and most medical providers throughout the country accept assignment with Medicare. As a result, these enrollees have a lot more options for medical providers than most of the rest of the population.

They can see any provider who accepts assignment, anywhere in the country. They can be assured that they will only have to pay their expected Medicare cost-sharing (deductible and coinsurance, some or all of which may be paid by a Medigap plan , Medicaid, or supplemental coverage provided by an employer or former employer).

It’s important to note here that the rules are different for the 29 million Americans who have Medicare Advantage plans. These beneficiaries cannot simply use any medical provider who accepts Medicare assignment.

Instead, each Medicare Advantage plan has its own network of providers —much like the health insurance plans that many Americans are accustomed to obtaining from employers or purchasing in the exchange/marketplace .

A provider who accepts assignment with Medicare may or may not be in-network with some or all of the Medicare Advantage plans that offer coverage in a given area. Some Medicare Advantage plans— health maintenance organizations (HMOs) , in particular—will only cover an enrollee’s claims if they use providers who are in the plan's network.

Other Medicare Advantage plans— preferred provider organizations (PPOs) , in particular—will cover out-of-network care but the enrollee will pay more than they would have paid had they seen an in-network provider.

Original Medicare

The bottom line is that Medicare assignment only determines provider accessibility and costs for people who have Original Medicare. People with Medicare Advantage need to understand their own plan’s provider network and coverage rules.

When discussing Medicare assignment and access to providers in this article, keep in mind that it is referring to people who have Original Medicare.

How to Make Sure Your Provider Accepts Assignment

Most doctors, hospitals, and other medical providers in the United States do accept Medicare assignment.

Provider Participation Stats

According to the Centers for Medicare and Medicaid Services, 98% of providers participate in Medicare, which means they accept assignment.

You can ask the provider directly about their participation with Medicare. But Medicare also has a tool that you can use to find participating doctors, hospitals, home health care services, and other providers.

There’s a filter on that tool labeled “Medicare-approved payment.” If you turn on that filter, you will only see providers who accept Medicare assignment. Under each provider’s information, it will say “Charges the Medicare-approved amount (so you pay less out-of-pocket).”

What If Your Provider Doesn’t Accept Assignment?

If your medical provider or equipment supplier doesn’t accept assignment, it means they haven’t agreed to accept Medicare’s approved amounts as payment in full for all of the services.

These providers can still choose to accept assignment on a case-by-case basis. But because they haven’t agreed to accept Medicare assignment for all services, they are considered nonparticipating providers.

Note that "nonparticipating" does not mean that a provider has opted out of Medicare altogether. Medicare will still pay claims for services received from a nonparticipating provider (i.e., one who does not accept Medicare assignment), whereas Medicare does not cover any of the cost of services obtained from a provider who has officially opted out of Medicare.

If a Medicare beneficiary uses a provider who has opted out of Medicare, that person will pay the provider directly and Medicare will not be involved in any way.

Physicians Who Have Opted Out

Only about 1% of all non-pediatric physicians have opted out of Medicare.

For providers who have not opted out of Medicare but who also don’t accept assignment, Medicare will still pay nearly as much as it would have paid if you had used a provider who accepts assignment. Here’s how it works:

• Medicare will pay the provider 95% of the amount they would pay if the provider accepted assignment.
• The provider can charge the person receiving care more than the Medicare-approved amount, but only up to 15% more (some states limit this further). This extra amount, which the patient has to pay out-of-pocket, is known as the limiting charge . But the 15% cap does not apply to medical equipment suppliers; if they do not accept assignment with Medicare, there is no limit on how much they can charge the person receiving care. This is why it’s particularly important to make sure that the supplier accepts Medicare assignment if you need medical equipment.
• The nonparticipating provider may require the person receiving care to pay the entire bill up front and seek reimbursement from Medicare (using Form CMS 1490-S ). Alternatively, they may submit a claim to Medicare on behalf of the person receiving care (using Form CMS-1500 ).
• A nonparticipating provider can choose to accept assignment on a case-by-case basis. They can indicate this on Form CMS-1500 in box 27. The vast majority of nonparticipating providers who bill Medicare choose to accept assignment for the claim being billed.
• Nonparticipating providers do not have to bill your Medigap plan on your behalf.

Billing Options for Providers Who Accept Medicare

When a medical provider accepts assignment with Medicare, part of the agreement is that they will submit bills to Medicare on behalf of the person receiving care. So if you only see providers who accept assignment, you will never need to submit your own bills to Medicare for reimbursement.

If you have a Medigap plan that supplements your Original Medicare coverage, you should present the Medigap coverage information to the provider at the time of service. Medicare will forward the claim information to your Medigap insurer, reducing administrative work on your part.

Depending on the Medigap plan you have, the services that you receive, and the amount you’ve already spent in out-of-pocket costs, the Medigap plan may pay some or all of the out-of-pocket costs that you would otherwise have after Medicare pays its share.

(Note that if you have a type of Medigap plan called Medicare SELECT, you will have to stay within the plan’s network of providers in order to receive benefits. But this is not the case with other Medigap plans.)

After the claim is processed, you’ll be able to see details in your MyMedicare.gov account . Medicare will also send you a Medicare Summary Notice. This is Medicare’s version of an explanation of benefits (EOB) , which is sent out every three months.

If you have a Medigap plan, it should also send you an EOB or something similar, explaining the claim and whether the policy paid any part of it.

What Is Medicare Assignment of Benefits?

For Medicare beneficiaries, assignment of benefits means that the person receiving care agrees to allow a nonparticipating provider to bill Medicare directly (as opposed to having the person receiving care pay the bill up front and seek reimbursement from Medicare). Assignment of benefits is authorized by the person receiving care in Box 13 of Form CMS-1500 .

If the person receiving care refuses to assign benefits, Medicare can only reimburse the person receiving care instead of paying the nonparticipating provider directly.

Things to Consider Before Choosing a Provider

If you’re enrolled in Original Medicare, you have a wide range of options in terms of the providers you can use—far more than most other Americans. In most cases, your preferred doctor and other medical providers will accept assignment with Medicare, keeping your out-of-pocket costs lower than they would otherwise be, and reducing administrative hassle.

There may be circumstances, however, when the best option is a nonparticipating provider or even a provider who has opted out of Medicare altogether. If you choose one of these options, be sure you discuss the details with the provider before proceeding with the treatment.

You’ll want to understand how much is going to be billed and whether the provider will bill Medicare on your behalf if you agree to assign benefits (note that this is not possible if the provider has opted out of Medicare).

If you have supplemental coverage, you’ll also want to check with that plan to see whether it will still pick up some of the cost and, if so, how much you should expect to pay out of your own pocket.

A medical provider who accepts Medicare assignment is considered a participating provider. These providers have agreed to accept Medicare’s fee schedule as payment in full for services they provide to Medicare beneficiaries. Most doctors, hospitals, and other medical providers do accept Medicare assignment.

Nonparticipating providers are those who have not signed an agreement with Medicare to accept Medicare’s rates as payment in full. However, they can agree to accept assignment on a case-by-case basis, as long as they haven’t opted out of Medicare altogether. If they do not accept assignment, they can bill the patient up to 15% more than the Medicare-approved rate.

Providers who opt out of Medicare cannot bill Medicare and Medicare will not pay them or reimburse beneficiaries for their services. But there is no limit on how much they can bill for their services.

A Word From Verywell

It’s in your best interest to choose a provider who accepts Medicare assignment. This will keep your costs as low as possible, streamline the billing and claims process, and ensure that your Medigap plan picks up its share of the costs.

If you feel like you need help navigating the provider options or seeking care from a provider who doesn’t accept assignment, the Medicare State Health Insurance Assistance Program (SHIP) in your state may be able to help.

A doctor who does not accept Medicare assignment has not agreed to accept Medicare’s fee schedule as payment in full for their services. These doctors are considered nonparticipating with Medicare and can bill Medicare beneficiaries up to 15% more than the Medicare-approved amount.

They also have the option to accept assignment (i.e., accept Medicare’s rate as payment in full) on a case-by-case basis.

There are certain circumstances in which a provider is required by law to accept assignment. This includes situations in which the person receiving care has both Medicare and Medicaid. And it also applies to certain medical services, including lab tests, ambulance services, and drugs that are covered under Medicare Part B (as opposed to Part D).

In 2021, 98% of American physicians had participation agreements with Medicare, leaving only about 2% who did not accept assignment (either as a nonparticipating provider, or a provider who had opted out of Medicare altogether).

Accepting assignment is something that the medical provider does, whereas assignment of benefits is something that the patient (the Medicare beneficiary) does. To accept assignment means that the medical provider has agreed to accept Medicare’s approved fee as payment in full for services they provide.

Assignment of benefits means that the person receiving care agrees to allow a medical provider to bill Medicare directly, as opposed to having the person receiving care pay the provider and then seek reimbursement from Medicare.

Centers for Medicare and Medicaid Services. Medicare monthly enrollment .

Centers for Medicare and Medicaid Services. Annual Medicare participation announcement .

Centers for Medicare and Medicaid Services. Lower costs with assignment .

Centers for Medicare and Medicaid Services. Find providers who have opted out of Medicare .

Kaiser Family Foundation. How many physicians have opted-out of the Medicare program ?

Center for Medicare Advocacy. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) updates .

Centers for Medicare and Medicaid Services. Check the status of a claim .

Centers for Medicare and Medicaid Services. Medicare claims processing manual. Chapter 26 - completing and processing form CMS-1500 data set .

Centers for Medicare and Medicaid Services. Ambulance fee schedule .

Centers for Medicare and Medicaid Services. Prescription drugs (outpatient) .

By Louise Norris Norris is a licensed health insurance agent, book author, and freelance writer. She graduated magna cum laude from Colorado State University.

Want to create or adapt books like this? Learn more about how Pressbooks supports open publishing practices.

3.3 Assignment

Nursing team members working in inpatient or long-term care settings receive patient assignments at the start of their shift. Assignment refers to routine care, activities, and procedures that are within the legal scope of practice of registered nurses (RN), licensed practical/vocational nurses (LPN/VN), or assistive personnel (AP). [1] Scope of practice for RNs and LPNs is described in each state’s Nurse Practice Act. Care tasks for AP vary by state; regulations are typically listed on sites for the state’s Board of Nursing, Department of Health, Department of Aging, Department of Health Professions, Department of Commerce, or Office of Long-Term Care. [2]

See Table 3.3a for common tasks performed by members of the nursing team based on their scope of practice. These tasks are within the traditional role and training the team member has acquired through a basic educational program. They are also within the expectations of the health care agency during a shift of work. Agency policy can be more restrictive than federal or state regulations, but it cannot be less restrictive.

Patient assignments are typically made by the charge nurse (or nurse supervisor) from the previous shift. A charge nurse is an RN who provides leadership on a patient-care unit within a health care facility during their shift. Charge nurses perform many of the tasks that general nurses do, but also have some supervisory duties such as making assignments, delegating tasks, preparing schedules, monitoring admissions and discharges, and serving as a staff member resource. [3]

Table 3.3a Nursing Team Members’ Scope of Practice and Common Tasks [4]

An example of a patient assignment is when an RN assigns an LPN/VN to care for a client with stable heart failure. The LPN/VN collects assessment data, monitors intake/output throughout the shift, and administers routine oral medication. The LPN/VN documents this information and reports information back to the RN. This is considered the LPN/VN’s “assignment” because the skills are taught within an LPN educational program and are consistent with the state’s Nurse Practice Act for LPN/VN scope of practice. They are also included in the unit’s job description for an LPN/VN. The RN may also assign some care for this client to AP. These tasks may include assistance with personal hygiene, toileting, and ambulation. The AP documents these tasks as they are completed and reports information back to the RN or LPN/VN. These tasks are considered the AP’s assignment because they are taught within a nursing aide’s educational program, are consistent with the AP’s scope of practice for that state, and are included in the job description for the nursing aide’s role in this unit. The RN continues to be accountable for the care provided to this client despite the assignments made to other nursing team members.

Special consideration is required for AP with additional training. With increased staffing needs, skills such as administering medications, inserting Foley catheters, or performing injections are included in specialized training programs for AP. Due to the impact these skills can have on the outcome and safety of the client, the National Council of State Board of Nursing (NCSBN) recommends these activities be considered delegated tasks by the RN or nurse leader. By delegating these advanced skills when appropriate, the nurse validates competency, provides supervision, and maintains accountability for client outcomes. Read more about delegation in the “ Delegation ” section of this chapter.

When making assignments to other nursing team members, it is essential for the RN to keep in mind specific tasks that cannot be delegated to other nursing team members based on federal and/or state regulations. These tasks include, but are not limited to, those tasks described in Table 3.3b.

Table 3.3b Examples of Tasks Outside the Scope of Practice of Nursing Assistive Personnel

As always, refer to each state’s Nurse Practice Act and other state regulations for specific details about nursing team members’ scope of practice when providing care in that state.

Find and review Nurse Practice Acts by state at www.ncsbn.org/npa.

Read more about the Wisconsin’s Nurse Practice Act and the standards and scope of practice for RNs and LPNs Wisconsin’s Legislative Code Chapter N6.

Read more about scope of practice, skills, and practices of nurse aides in Wisconsin at DHS 129.07 Standards for Nurse Aide Training Programs.

• American Nurses Association and NCSBN. (2019). National guidelines for nursing delegation . https://www.ncsbn.org/NGND-PosPaper_06.pdf ↵
• McMullen, T. L., Resnick, B., Chin-Hansen, J., Geiger-Brown, J. M., Miller, N., & Rubenstein, R. (2015). Certified nurse aide scope of practice: State-by-state differences in allowable delegated activities. Journal of the American Medical Directors Association, 16 (1), 20–24. https://doi.org/10.1016/j.jamda.2014.07.003 ↵
• RegisteredNursing.org. (2021, April 13). What is a charge nurse? https://www.registerednursing.org/specialty/charge-nurse/ ↵
• RegisteredNursing.org. (2021, January 27). Assignment, delegation and supervision: NCLEX-RN. https://www.registerednursing.org/nclex/assignment-delegation-supervision/ ↵
• State of Wisconsin Department of Health Services. (2018). Medication administration by unlicensed assistive personnel (UAP): Guidelines for registered nurses delegating medication administration to unlicensed assistive personnel. https://www.dhs.wisconsin.gov/publications/p01908.pdf ↵

Routine care, activities, and procedures that are within the authorized scope of practice of the RN, LPN/VN, or routine functions of the assistive personnel.

Making adjustments to medication dosage per an established protocol to obtain a desired therapeutic outcome.

Nursing Management and Professional Concepts Copyright © by Chippewa Valley Technical College is licensed under a Creative Commons Attribution 4.0 International License , except where otherwise noted.

Share This Book

The Nurse-Patient Assignment: Purposes and Decision Factors

Affiliation.

• 1 Author Affiliation: Assistant Professor, Pace University, Pleasantville, New York.
• PMID: 26565641
• DOI: 10.1097/NNA.0000000000000276

Objective: Identify purposes and decision factors of the nurse-patient assignment process.

Background: Nurse-patient assignments can positively impact patient, nurse, and environmental outcomes.

Methods: This was an exploratory study involving interviews with 14 charge nurses from 11 different nursing units in 1 community hospital.

Results: Charge nurses identified 14 purposes and 17 decision factors of the nurse-patient assignment process.

Conclusions: The nurse-patient assignment is a complex process driven by the patient, nurse, and environment. Further study is needed to identify factors linked to patient safety, nurse, and environmental outcomes.

• Decision Making, Organizational*
• Hospitals, Voluntary / organization & administration
• Middle Aged
• Nurse-Patient Relations*
• Nursing Administration Research / methods
• Nursing Staff, Hospital / organization & administration*
• Nursing Staff, Hospital / standards
• Nursing, Supervisory / organization & administration*
• Nursing, Supervisory / standards
• Patient Safety*
• Personnel Staffing and Scheduling / organization & administration
• Personnel Staffing and Scheduling / standards*
• Southeastern United States

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022.

Nursing Management and Professional Concepts [Internet].

• About Open RN

Chapter 2 - Prioritization

2.1. prioritization introduction, learning objectives.

• Prioritize nursing care based on patient acuity

• Use principles of time management to organize work

• Analyze effectiveness of time management strategies

• Use critical thinking to prioritize nursing care for patients

• Apply a framework for prioritization (e.g., Maslow, ABCs)

“So much to do, so little time.” This is a common mantra of today’s practicing nurse in various health care settings. Whether practicing in acute inpatient care, long-term care, clinics, home care, or other agencies, nurses may feel there is “not enough of them to go around.”

The health care system faces a significant challenge in balancing the ever-expanding task of meeting patient care needs with scarce nursing resources that has even worsened as a result of the COVID-19 pandemic. With a limited supply of registered nurses, nurse managers are often challenged to implement creative staffing practices such as sending staff to units where they do not normally work (i.e., floating), implementing mandatory staffing and/or overtime, utilizing travel nurses, or using other practices to meet patient care demands.[ 1 ] Staffing strategies can result in nurses experiencing increased patient assignments and workloads, extended shifts, or temporary suspension of paid time off. Nurses may receive a barrage of calls and text messages offering “extra shifts” and bonus pay, and although the extra pay may be welcomed, they often eventually feel burnt out trying to meet the ever-expanding demands of the patient-care environment.

A novice nurse who is still learning how to navigate the complex health care environment and provide optimal patient care may feel overwhelmed by these conditions. Novice nurses frequently report increased levels of stress and disillusionment as they transition to the reality of the nursing role.[ 2 ] How can we address this professional dilemma and enhance the novice nurse’s successful role transition to practice? The novice nurse must enter the profession with purposeful tools and strategies to help prioritize tasks and manage time so they can confidently address patient care needs, balance role demands, and manage day-to-day nursing activities.

Let’s take a closer look at the foundational concepts related to prioritization and time management in the nursing profession.

2.2. TENETS OF PRIORITIZATION

Prioritization.

As new nurses begin their career, they look forward to caring for others, promoting health, and saving lives. However, when entering the health care environment, they often discover there are numerous and competing demands for their time and attention. Patient care is often interrupted by call lights, rounding physicians, and phone calls from the laboratory department or other interprofessional team members. Even individuals who are strategic and energized in their planning can feel frustrated as their task lists and planned patient-care activities build into a long collection of “to dos.”

Without utilization of appropriate prioritization strategies, nurses can experience  time scarcity , a feeling of racing against a clock that is continually working against them. Functioning under the burden of time scarcity can cause feelings of frustration, inadequacy, and eventually burnout. Time scarcity can also impact patient safety, resulting in adverse events and increased mortality.[ 1 ] Additionally, missed or rushed nursing activities can negatively impact patient satisfaction scores that ultimately affect an institution’s reimbursement levels.

It is vital for nurses to plan patient care and implement their task lists while ensuring that critical interventions are safely implemented first. Identifying priority patient problems and implementing priority interventions are skills that require ongoing cultivation as one gains experience in the practice environment.[ 2 ] To develop these skills, students must develop an understanding of organizing frameworks and prioritization processes for delineating care needs. These frameworks provide structure and guidance for meeting the multiple and ever-changing demands in the complex health care environment.

Let’s consider a clinical scenario in the following box to better understand the implications of prioritization and outcomes.

Imagine you are beginning your shift on a busy medical-surgical unit. You receive a handoff report on four medical-surgical patients from the night shift nurse:

• Patient A is a 34-year-old total knee replacement patient, post-op Day 1, who had an uneventful night. It is anticipated that she will be discharged today and needs patient education for self-care at home.

• Patient B is a 67-year-old male admitted with weakness, confusion, and a suspected urinary tract infection. He has been restless and attempting to get out of bed throughout the night. He has a bed alarm in place.

• Patient C is a 49-year-old male, post-op Day 1 for a total hip replacement. He has been frequently using his patient-controlled analgesia (PCA) pump and last rated his pain as a “6.”

• Patient D is a 73-year-old male admitted for pneumonia. He has been hospitalized for three days and receiving intravenous (IV) antibiotics. His next dose is due in an hour. His oxygen requirements have decreased from 4 L/minute of oxygen by nasal cannula to 2 L/minute by nasal cannula.

Based on the handoff report you received, you ask the nursing assistant to check on Patient B while you do an initial assessment on Patient D. As you are assessing Patient D’s oxygenation status, you receive a phone call from the laboratory department relating a critical lab value on Patient C, indicating his hemoglobin is low. The provider calls and orders a STAT blood transfusion for Patient C. Patient A rings the call light and states she and her husband have questions about her discharge and are ready to go home. The nursing assistant finds you and reports that Patient B got out of bed and experienced a fall during the handoff reports.

It is common for nurses to manage multiple and ever-changing tasks and activities like this scenario, illustrating the importance of self-organization and priority setting. This chapter will further discuss the tools nurses can use for prioritization.

2.3. TOOLS FOR PRIORITIZING

Prioritization of care for multiple patients while also performing daily nursing tasks can feel overwhelming in today’s fast-paced health care system. Because of the rapid and ever-changing conditions of patients and the structure of one’s workday, nurses must use organizational frameworks to prioritize actions and interventions. These frameworks can help ease anxiety, enhance personal organization and confidence, and ensure patient safety.

Acuity and intensity are foundational concepts for prioritizing nursing care and interventions.  Acuity  refers to the level of patient care that is required based on the severity of a patient’s illness or condition. For example, acuity may include characteristics such as unstable vital signs, oxygenation therapy, high-risk IV medications, multiple drainage devices, or uncontrolled pain. A “high-acuity” patient requires several nursing interventions and frequent nursing assessments.

Intensity addresses the time needed to complete nursing care and interventions such as providing assistance with activities of daily living (ADLs), performing wound care, or administering several medication passes. For example, a “high-intensity” patient generally requires frequent or long periods of psychosocial, educational, or hygiene care from nursing staff members. High-intensity patients may also have increased needs for safety monitoring, familial support, or other needs.[ 1 ]

Many health care organizations structure their staffing assignments based on acuity and intensity ratings to help provide equity in staff assignments. Acuity helps to ensure that nursing care is strategically divided among nursing staff. An equitable assignment of patients benefits both the nurse and patient by helping to ensure that patient care needs do not overwhelm individual staff and safe care is provided.

Organizations use a variety of systems when determining patient acuity with rating scales based on nursing care delivery, patient stability, and care needs. See an example of a patient acuity tool published in the  American Nurse  in Table 2.3 .[ 2 ] In this example, ratings range from 1 to 4, with a rating of 1 indicating a relatively stable patient requiring minimal individualized nursing care and intervention. A rating of 2 reflects a patient with a moderate risk who may require more frequent intervention or assessment. A rating of 3 is attributed to a complex patient who requires frequent intervention and assessment. This patient might also be a new admission or someone who is confused and requires more direct observation. A rating of 4 reflects a high-risk patient. For example, this individual may be experiencing frequent changes in vital signs, may require complex interventions such as the administration of blood transfusions, or may be experiencing significant uncontrolled pain. An individual with a rating of 4 requires more direct nursing care and intervention than a patient with a rating of 1 or 2. [3]

Example of a Patient Acuity Tool [ 4 ]

View in own window

Read more about using a  patient acuity tool on a medical-surgical unit.

Rating scales may vary among institutions, but the principles of the rating system remain the same. Organizations include various patient care elements when constructing their staffing plans for each unit. Read more information about staffing models and acuity in the following box.

Staffing Models and Acuity

Organizations that base staffing on acuity systems attempt to evenly staff patient assignments according to their acuity ratings. This means that when comparing patient assignments across nurses on a unit, similar acuity team scores should be seen with the goal of achieving equitable and safe division of workload across the nursing team. For example, one nurse should not have a total acuity score of 6 for their patient assignments while another nurse has a score of 15. If this situation occurred, the variation in scoring reflects a discrepancy in workload balance and would likely be perceived by nursing peers as unfair. Using  acuity-rating staffing models  is helpful to reflect the individualized nursing care required by different patients.

Alternatively, nurse staffing models may be determined by staffing ratio.  Ratio-based staffing models  are more straightforward in nature, where each nurse is assigned care for a set number of patients during their shift. Ratio-based staffing models may be useful for administrators creating budget requests based on the number of staff required for patient care, but can lead to an inequitable division of work across the nursing team when patient acuity is not considered. Increasingly complex patients require more time and interventions than others, so a blend of both ratio and acuity-based staffing is helpful when determining staffing assignments.[ 5 ]

As a practicing nurse, you will be oriented to the elements of acuity ratings within your health care organization, but it is also important to understand how you can use these acuity ratings for your own prioritization and task delineation. Let’s consider the Scenario B in the following box to better understand how acuity ratings can be useful for prioritizing nursing care.

You report to work at 6 a.m. for your nursing shift on a busy medical-surgical unit. Prior to receiving the handoff report from your night shift nursing colleagues, you review the unit staffing grid and see that you have been assigned to four patients to start your day. The patients have the following acuity ratings:

Patient A: 45-year-old patient with paraplegia admitted for an infected sacral wound, with an acuity rating of 4.

Patient B: 87-year-old patient with pneumonia with a low grade fever of 99.7 F and receiving oxygen at 2 L/minute via nasal cannula, with an acuity rating of 2.

Patient C: 63-year-old patient who is postoperative Day 1 from a right total hip replacement and is receiving pain management via a PCA pump, with an acuity rating of 2.

Patient D: 83-year-old patient admitted with a UTI who is finishing an IV antibiotic cycle and will be discharged home today, with an acuity rating of 1.

Based on the acuity rating system, your patient assignment load receives an overall acuity score of 9. Consider how you might use their acuity ratings to help you prioritize your care. Based on what is known about the patients related to their acuity rating, whom might you identify as your care priority? Although this can feel like a challenging question to answer because of the many unknown elements in the situation using acuity numbers alone, Patient A with an acuity rating of 4 would be identified as the care priority requiring assessment early in your shift.

Although acuity can a useful tool for determining care priorities, it is important to recognize the limitations of this tool and consider how other patient needs impact prioritization.

Maslow’s Hierarchy of Needs

When thinking back to your first nursing or psychology course, you may recall a historical theory of human motivation based on various levels of human needs called Maslow’s Hierarchy of Needs.  Maslow’s Hierarchy of Needs  reflects foundational human needs with progressive steps moving towards higher levels of achievement. This hierarchy of needs is traditionally represented as a pyramid with the base of the pyramid serving as essential needs that must be addressed before one can progress to another area of need.[ 6 ] See Figure 2.1  [ 7 ] for an illustration of Maslow’s Hierarchy of Needs.

Maslow’s Hierarchy of Needs places physiological needs as the foundational base of the pyramid.[ 8 ] Physiological needs include oxygen, food, water, sex, sleep, homeostasis, and excretion. The second level of Maslow’s hierarchy reflects safety needs. Safety needs include elements that keep individuals safe from harm. Examples of safety needs in health care include fall precautions. The third level of Maslow’s hierarchy reflects emotional needs such as love and a sense of belonging. These needs are often reflected in an individual’s relationships with family members and friends. The top two levels of Maslow’s hierarchy include esteem and self-actualization. An example of addressing these needs in a health care setting is helping an individual build self-confidence in performing blood glucose checks that leads to improved self-management of their diabetes.

So how does Maslow’s theory impact prioritization? To better understand the application of Maslow’s theory to prioritization, consider Scenario C in the following box.

You are an emergency response nurse working at a local shelter in a community that has suffered a devastating hurricane. Many individuals have relocated to the shelter for safety in the aftermath of the hurricane. Much of the community is still without electricity and clean water, and many homes have been destroyed. You approach a young woman who has a laceration on her scalp that is bleeding through her gauze dressing. The woman is weeping as she describes the loss of her home stating, “I have lost everything! I just don’t know what I am going to do now. It has been a day since I have had water or anything to drink. I don’t know where my sister is, and I can’t reach any of my family to find out if they are okay!”

Despite this relatively brief interaction, this woman has shared with you a variety of needs. She has demonstrated a need for food, water, shelter, homeostasis, and family. As the nurse caring for her, it might be challenging to think about where to begin her care. These thoughts could be racing through your mind:

Should I begin to make phone calls to try and find her family? Maybe then she would be able to calm down.

Should I get her on the list for the homeless shelter so she wouldn’t have to worry about where she will sleep tonight?

She hasn’t eaten in awhile; I should probably find her something to eat.

All of these needs are important and should be addressed at some point, but Maslow’s hierarchy provides guidance on what needs must be addressed first. Use the foundational level of Maslow’s pyramid of physiological needs as the top priority for care. The woman is bleeding heavily from a head wound and has had limited fluid intake. As the nurse caring for this patient, it is important to immediately intervene to stop the bleeding and restore fluid volume. Stabilizing the patient by addressing her physiological needs is required before undertaking additional measures such as contacting her family. Imagine if instead you made phone calls to find the patient’s family and didn’t address the bleeding or dehydration – you might return to a severely hypovolemic patient who has deteriorated and may be near death. In this example, prioritizing emotional needs above physiological needs can lead to significant harm to the patient.

Although this is a relatively straightforward example, the principles behind the application of Maslow’s hierarchy are essential. Addressing physiological needs before progressing toward additional need categories concentrates efforts on the most vital elements to enhance patient well-being. Maslow’s hierarchy provides the nurse with a helpful framework for identifying and prioritizing critical patient care needs.

Airway, breathing, and circulation, otherwise known by the mnemonic “ABCs,” are another foundational element to assist the nurse in prioritization. Like Maslow’s hierarchy, using the ABCs to guide decision-making concentrates on the most critical needs for preserving human life. If a patient does not have a patent airway, is unable to breathe, or has inadequate circulation, very little of what else we do matters. The patient’s  ABCs  are reflected in Maslow’s foundational level of physiological needs and direct critical nursing actions and timely interventions. Let’s consider Scenario D in the following box regarding prioritization using the ABCs and the physiological base of Maslow’s hierarchy.

You are a nurse on a busy cardiac floor charting your morning assessments on a computer at the nurses’ station. Down the hall from where you are charting, two of your assigned patients are resting comfortably in Room 504 and Room 506. Suddenly, both call lights ring from the rooms, and you answer them via the intercom at the nurses’ station.

Room 504 has an 87-year-old male who has been admitted with heart failure, weakness, and confusion. He has a bed alarm for safety and has been ringing his call bell for assistance appropriately throughout the shift. He requires assistance to get out of bed to use the bathroom. He received his morning medications, which included a diuretic about 30 minutes previously, and now reports significant urge to void and needs assistance to the bathroom.

Room 506 has a 47-year-old woman who was hospitalized with new onset atrial fibrillation with rapid ventricular response. The patient underwent a cardioversion procedure yesterday that resulted in successful conversion of her heart back into normal sinus rhythm. She is reporting via the intercom that her “heart feels like it is doing that fluttering thing again” and she is having chest pain with breathlessness.

Based upon these two patient scenarios, it might be difficult to determine whom you should see first. Both patients are demonstrating needs in the foundational physiological level of Maslow’s hierarchy and require assistance. To prioritize between these patients’ physiological needs, the nurse can apply the principles of the ABCs to determine intervention. The patient in Room 506 reports both breathing and circulation issues, warning indicators that action is needed immediately. Although the patient in Room 504 also has an urgent physiological elimination need, it does not overtake the critical one experienced by the patient in Room 506. The nurse should immediately assess the patient in Room 506 while also calling for assistance from a team member to assist the patient in Room 504.

Prioritizing what should be done and when it can be done can be a challenging task when several patients all have physiological needs. Recently, there has been professional acknowledgement of the cognitive challenge for novice nurses in differentiating physiological needs. To expand on the principles of prioritizing using the ABCs, the CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to guide prioritization based on identifying the differences among Critical needs, Urgent needs, Routine needs, and Extras.[ 9 ]

“Critical” patient needs require immediate action. Examples of critical needs align with the ABCs and Maslow’s physiological needs, such as symptoms of respiratory distress, chest pain, and airway compromise. No matter the complexity of their shift, nurses can be assured that addressing patients’ critical needs is the correct prioritization of their time and energies.

After critical patient care needs have been addressed, nurses can then address “urgent” needs. Urgent needs are characterized as needs that cause patient discomfort or place the patient at a significant safety risk.[ 10 ]

The third part of the CURE hierarchy reflects “routine” patient needs. Routine patient needs can also be characterized as “typical daily nursing care” because the majority of a standard nursing shift is spent addressing routine patient needs. Examples of routine daily nursing care include actions such as administering medication and performing physical assessments.[ 11 ] Although a nurse’s typical shift in a hospital setting includes these routine patient needs, they do not supersede critical or urgent patient needs.

The final component of the CURE hierarchy is known as “extras.” Extras refer to activities performed in the care setting to facilitate patient comfort but are not essential.[ 12 ] Examples of extra activities include providing a massage for comfort or washing a patient’s hair. If a nurse has sufficient time to perform extra activities, they contribute to a patient’s feeling of satisfaction regarding their care, but these activities are not essential to achieve patient outcomes.

Let’s apply the CURE mnemonic to patient care in the following box.

If we return to Scenario D regarding patients in Room 504 and 506, we can see the patient in Room 504 is having urgent needs. He is experiencing a physiological need to urgently use the restroom and may also have safety concerns if he does not receive assistance and attempts to get up on his own because of weakness. He is on a bed alarm, which reflects safety considerations related to his potential to get out of bed without assistance. Despite these urgent indicators, the patient in Room 506 is experiencing a critical need and takes priority. Recall that critical needs require immediate nursing action to prevent patient deterioration. The patient in Room 506 with a rapid, fluttering heartbeat and shortness of breath has a critical need because without prompt assessment and intervention, their condition could rapidly decline and become fatal.

In addition to using the identified frameworks and tools to assist with priority setting, nurses must also look at their patients’ data cues to help them identify care priorities.  Data cues  are pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition. For example, have the patient’s vital signs worsened over the last few hours? Is there a new laboratory result that is concerning? Data cues are used in conjunction with prioritization frameworks to help the nurse holistically understand the patient’s current status and where nursing interventions should be directed. Common categories of data clues include acute versus chronic conditions, actual versus potential problems, unexpected versus expected conditions, information obtained from the review of a patient’s chart, and diagnostic information.

Acute Versus Chronic Conditions

A common data cue that nurses use to prioritize care is considering if a condition or symptom is acute or chronic.  Acute conditions  have a sudden and severe onset. These conditions occur due to a sudden illness or injury, and the body often has a significant response as it attempts to adapt.  Chronic conditions  have a slow onset and may gradually worsen over time. The difference between an acute versus a chronic condition relates to the body’s adaptation response. Individuals with chronic conditions often experience less symptom exacerbation because their body has had time to adjust to the illness or injury. Let’s consider an example of two patients admitted to the medical-surgical unit complaining of pain in Scenario E in the following box.

As part of your patient assignment on a medical-surgical unit, you are caring for two patients who both ring the call light and report pain at the start of the shift. Patient A was recently admitted with acute appendicitis, and Patient B was admitted for observation due to weakness. Not knowing any additional details about the patients’ conditions or current symptoms, which patient would receive priority in your assessment? Based on using the data cue of acute versus chronic conditions, Patient A with a diagnosis of acute appendicitis would receive top priority for assessment over a patient with chronic pain due to osteoarthritis. Patients experiencing acute pain require immediate nursing assessment and intervention because it can indicate a change in condition. Acute pain also elicits physiological effects related to the stress response, such as elevated heart rate, blood pressure, and respiratory rate, and should be addressed quickly.

Actual Versus Potential Problems

Nursing diagnoses and the nursing care plan have significant roles in directing prioritization when interpreting assessment data cues.  Actual problems  refer to a clinical problem that is actively occurring with the patient. A  risk problem  indicates the patient may potentially experience a problem but they do not have current signs or symptoms of the problem actively occurring.

Consider an example of prioritizing actual and potential problems in Scenario F in the following box.

A 74-year-old woman with a previous history of chronic obstructive pulmonary disease (COPD) is admitted to the hospital for pneumonia. She has generalized weakness, a weak cough, and crackles in the bases of her lungs. She is receiving IV antibiotics, fluids, and oxygen therapy. The patient can sit at the side of the bed and ambulate with the assistance of staff, although she requires significant encouragement to ambulate.

Nursing diagnoses are established for this patient as part of the care planning process. One nursing diagnosis for this patient is  Ineffective Airway Clearance . This nursing diagnosis is an actual problem because the patient is currently exhibiting signs of poor airway clearance with an ineffective cough and crackles in the lungs. Nursing interventions related to this diagnosis include coughing and deep breathing, administering nebulizer treatment, and evaluating the effectiveness of oxygen therapy. The patient also has the nursing diagnosis  Risk for   Skin Breakdown  based on her weakness and lack of motivation to ambulate. Nursing interventions related to this diagnosis include repositioning every two hours and assisting with ambulation twice daily.

The established nursing diagnoses provide cues for prioritizing care. For example, if the nurse enters the patient’s room and discovers the patient is experiencing increased shortness of breath, nursing interventions to improve the patient’s respiratory status receive top priority before attempting to get the patient to ambulate.

Although there may be times when risk problems may supersede actual problems, looking to the “actual” nursing problems can provide clues to assist with prioritization.

Unexpected Versus Expected Conditions

In a similar manner to using acute versus chronic conditions as a cue for prioritization, it is also important to consider if a client’s signs and symptoms are “expected” or “unexpected” based on their overall condition.  Unexpected conditions  are findings that are not likely to occur in the normal progression of an illness, disease, or injury.  Expected conditions  are findings that are likely to occur or are anticipated in the course of an illness, disease, or injury. Unexpected findings often require immediate action by the nurse.

Let’s apply this tool to the two patients previously discussed in Scenario E. As you recall, both Patient A (with acute appendicitis) and Patient B (with weakness and diagnosed with osteoarthritis) are reporting pain. Acute pain typically receives priority over chronic pain. But what if both patients are also reporting nausea and have an elevated temperature? Although these symptoms must be addressed in both patients, they are “expected” symptoms with acute appendicitis (and typically addressed in the treatment plan) but are “unexpected” for the patient with osteoarthritis. Critical thinking alerts you to the unexpected nature of these symptoms in Patient B, so they receive priority for assessment and nursing interventions.

Handoff Report/Chart Review

Additional data cues that are helpful in guiding prioritization come from information obtained during a handoff nursing report and review of the patient chart. These data cues can be used to establish a patient’s baseline status and prioritize new clinical concerns based on abnormal assessment findings. Let’s consider Scenario G in the following box based on cues from a handoff report and how it might be used to help prioritize nursing care.

Imagine you are receiving the following handoff report from the night shift nurse for a patient admitted to the medical-surgical unit with pneumonia:

At the beginning of my shift, the patient was on room air with an oxygen saturation of 93%. She had slight crackles in both bases of her posterior lungs. At 0530, the patient rang the call light to go to the bathroom. As I escorted her to the bathroom, she appeared slightly short of breath. Upon returning the patient to bed, I rechecked her vital signs and found her oxygen saturation at 88% on room air and respiratory rate of 20. I listened to her lung sounds and noticed more persistent crackles and coarseness than at bedtime. I placed the patient on 2 L/minute of oxygen via nasal cannula. Within 5 minutes, her oxygen saturation increased to 92%, and she reported increased ease in respiration.

Based on the handoff report, the night shift nurse provided substantial clinical evidence that the patient may be experiencing a change in condition. Although these changes could be attributed to lack of lung expansion that occurred while the patient was sleeping, there is enough information to indicate to the oncoming nurse that follow-up assessment and interventions should be prioritized for this patient because of potentially worsening respiratory status. In this manner, identifying data cues from a handoff report can assist with prioritization.

Now imagine the night shift nurse had not reported this information during the handoff report. Is there another method for identifying potential changes in patient condition? Many nurses develop a habit of reviewing their patients’ charts at the start of every shift to identify trends and “baselines” in patient condition. For example, a chart review reveals a patient’s heart rate on admission was 105 beats per minute. If the patient continues to have a heart rate in the low 100s, the nurse is not likely to be concerned if today’s vital signs reveal a heart rate in the low 100s. Conversely, if a patient’s heart rate on admission was in the 60s and has remained in the 60s throughout their hospitalization, but it is now in the 100s, this finding is an important cue requiring prioritized assessment and intervention.

Diagnostic Information

Diagnostic results are also important when prioritizing care. In fact, the National Patient Safety Goals from The Joint Commission include prompt reporting of important test results. New abnormal laboratory results are typically flagged in a patient’s chart or are reported directly by phone to the nurse by the laboratory as they become available. Newly reported abnormal results, such as elevated blood levels or changes on a chest X-ray, may indicate a patient’s change in condition and require additional interventions. For example, consider Scenario H in which you are the nurse providing care for five medical-surgical patients.

You completed morning assessments on your assigned five patients. Patient A previously underwent a total right knee replacement and will be discharged home today. You are about to enter Patient A’s room to begin discharge teaching when you receive a phone call from the laboratory department, reporting a critical hemoglobin of 6.9 gm/dL on Patient B. Rather than enter Patient A’s room to perform discharge teaching, you immediately reprioritize your care. You call the primary provider to report Patient B’s critical hemoglobin level and determine if additional intervention, such as a blood transfusion, is required.

2.4. CRITICAL THINKING AND CLINICAL REASONING

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.” [2]

When nurses use critical thinking and clinical reasoning skills, they set forth on a purposeful course of intervention to best meet patient-care needs. Rather than focusing on one’s own priorities, nurses utilizing critical thinking and reasoning skills recognize their actions must be responsive to their patients. For example, a nurse using critical thinking skills understands that scheduled morning medications for their patients may be late if one of the patients on their care team suddenly develops chest pain. Many actions may be added or removed from planned activities throughout the shift based on what is occurring holistically on the patient-care team.

Additionally, in today’s complex health care environment, it is important for the novice nurse to recognize the realities of the current health care environment. Patients have become increasingly complex in their health care needs, and organizations are often challenged to meet these care needs with limited staffing resources. It can become easy to slip into the mindset of disenchantment with the nursing profession when first assuming the reality of patient-care assignments as a novice nurse. The workload of a nurse in practice often looks and feels quite different than that experienced as a nursing student. As a nursing student, there may have been time for lengthy conversations with patients and their family members, ample time to chart, and opportunities to offer personal cares, such as a massage or hair wash. Unfortunately, in the time-constrained realities of today’s health care environment, novice nurses should recognize that even though these “extra” tasks are not always possible, they can still provide quality, safe patient care using the “CURE” prioritization framework. Rather than feeling frustrated about “extras” that cannot be accomplished in time-constrained environments, it is vital to use prioritization strategies to ensure appropriate actions are taken to complete what must be done. With increased clinical experience, a novice nurse typically becomes more comfortable with prioritizing and reprioritizing care.

Prioritization of patient care should be grounded in critical thinking rather than just a checklist of items to be done.  Critical thinking  is a broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 1 ] Certainly, there are many actions that nurses must complete during their shift, but nursing requires adaptation and flexibility to meet emerging patient needs. It can be challenging for a novice nurse to change their mindset regarding their established “plan” for the day, but the sooner a nurse recognizes prioritization is dictated by their patients’ needs, the less frustration the nurse might experience. Prioritization strategies include collection of information and utilization of clinical reasoning to determine the best course of action.  Clinical reasoning  is defined as, “A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 2 ]

2.7. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activities are provided as immediate feedback.)

The CURE hierarchy has been introduced to help novice nurses better understand how to manage competing patient needs. The CURE hierarchy uses the acronym “CURE” to help guide prioritization based on identifying the differences among  C ritical needs,  U rgent needs,  R outine needs, and  E xtras.

You are the nurse caring for the patients in the following table. For each patient, indicate if this is a “critical,” “urgent,” “routine,” or “extra” need.

II. GLOSSARY

Airway, breathing, and circulation.

Nursing problems currently occurring with the patient.

The level of patient care that is required based on the severity of a patient’s illness or condition.

A staffing model used to make patient assignments that reflects the individualized nursing care required for different types of patients.

Conditions having a sudden onset.

Conditions that have a slow onset and may gradually worsen over time.

A complex cognitive process that uses formal and informal thinking strategies to gather and analyze patient information, evaluate the significance of this information, and weigh alternative actions.”[ 1 ]

A broad term used in nursing that includes “reasoning about clinical issues such as teamwork, collaboration, and streamlining workflow.”[ 2 ]

A strategy for prioritization based on identifying “critical” needs, “urgent” needs, “routine” needs, and “extras.”

Pieces of significant clinical information that direct the nurse toward a potential clinical concern or a change in condition.

Conditions that are likely to occur or anticipated in the course of an illness, disease, or injury.

Prioritization strategies often reflect the foundational elements of physiological needs and safety and progr ess toward higher levels.

A staffing model used to make patient assignments in terms of one nurse caring for a set number of patients.

A nursing problem that reflects that a patient may experience a problem but does not currently have signs reflecting the problem is actively occurring.

A prioritization strategy including the review of planned tasks and allocation of time believed to be required to complete each task.

A feeling of racing against a clock that is continually working against you.

Conditions that are not likely to occur in the normal progression of an illness, disease, or injury.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Management and Professional Concepts [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2022. Chapter 2 - Prioritization.
• PDF version of this title (18M)

In this Page

• PRIORITIZATION INTRODUCTION
• TENETS OF PRIORITIZATION
• TOOLS FOR PRIORITIZING
• CRITICAL THINKING AND CLINICAL REASONING
• LEARNING ACTIVITIES

Other titles in this collection

• Open RN OER Textbooks

Related Items in Bookshelf

• All Textbooks

Related information

• PMC PubMed Central citations
• PubMed Links to PubMed

Recent Activity

• Chapter 2 - Prioritization - Nursing Management and Professional Concepts Chapter 2 - Prioritization - Nursing Management and Professional Concepts

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

Find cars that meet your safety needs with AARP Auto Buying Program powered by TrueCar. Learn more.

AARP daily Crossword Puzzle

Hotels with AARP discounts

Life Insurance

AARP Dental Insurance Plans

AARP MEMBERSHIP — $12 FOR YOUR FIRST YEAR WHEN YOU SIGN UP FOR AUTOMATIC RENEWAL

Get instant access to members-only products and hundreds of discounts, a free second membership, and a subscription to AARP the Magazine.

• right_container

Work & Jobs

Social Security

AARP en Español

• Membership & Benefits

AARP Rewards

• AARP Rewards %{points}%

Conditions & Treatments

Drugs & Supplements

Health Care & Coverage

Health Benefits

Staying Fit

Your Personalized Guide to Fitness

AARP Hearing Center

Ways To Improve Your Hearing

Brain Health Resources

Tools and Explainers on Brain Health

A Retreat For Those Struggling

Scams & Fraud

Personal Finance

Money Benefits

View and Report Scams in Your Area

AARP Foundation Tax-Aide

Free Tax Preparation Assistance

AARP Money Map

Get Your Finances Back on Track

How to Protect What You Collect

Small Business

Age Discrimination

Flexible Work

Freelance Jobs You Can Do From Home

AARP Skills Builder

Online Courses to Boost Your Career

31 Great Ways to Boost Your Career

ON-DEMAND WEBINARS

Tips to Enhance Your Job Search

Get More out of Your Benefits

When to Start Taking Social Security

10 Top Social Security FAQs

Social Security Benefits Calculator

Medicare Made Easy

Original vs. Medicare Advantage

Enrollment Guide

Step-by-Step Tool for First-Timers

Prescription Drugs

9 Biggest Changes Under New Rx Law

Medicare FAQs

Quick Answers to Your Top Questions

Care at Home

Financial & Legal

Life Balance

LONG-TERM CARE

​Understanding Basics of LTC Insurance​

State Guides

Assistance and Services in Your Area

Prepare to Care Guides

How to Develop a Caregiving Plan

End of Life

How to Cope With Grief, Loss

Recently Played

Word & Trivia

Atari® & Retro

Members Only

Staying Sharp

Mobile Apps

More About Games

Right Again! Trivia

Right Again! Trivia – Sports

Atari® Video Games

Throwback Thursday Crossword

Travel Tips

Vacation Ideas

Destinations

Travel Benefits

Outdoor Vacation Ideas

Camping Vacations

Plan Ahead for Summer Travel

AARP National Park Guide

Discover Canyonlands National Park

25 Ways to Save on Your Vacation

Entertainment & Style

Family & Relationships

Personal Tech

Home & Living

Celebrities

Beauty & Style

TV for Grownups

Best Reality TV Shows for Grownups

Robert De Niro Reflects on His Life

Looking Back

50 World Changers Turning 50

Sex & Dating

Spice Up Your Love Life

Navigate All Kinds of Connections

Life & Home

Couple Creates Their Forever Home

Home Technology

Caregiver’s Guide to Smart Home Tech

AI Technology

The Possibilities, Perils of AI

Virtual Community Center

Join Free Tech Help Events

Create a Hygge Haven

Soups to Comfort Your Soul

Your Ultimate Guide to Mulching

Driver Safety

Maintenance & Safety

Trends & Technology

AARP Smart Guide

How to Keep Your Car Running

We Need To Talk

Assess Your Loved One's Driving Skills

AARP Smart Driver Course

Building Resilience in Difficult Times

Tips for Finding Your Calm

Weight Loss After 50 Challenge

Cautionary Tales of Today's Biggest Scams

7 Top Podcasts for Armchair Travelers

Jean Chatzky: ‘Closing the Savings Gap’

Quick Digest of Today's Top News

AARP Top Tips for Navigating Life

Get Moving With Our Workout Series

You are now leaving AARP.org and going to a website that is not operated by AARP. A different privacy policy and terms of service will apply.

Go to Series Main Page

What is Medicare assignment and how does it work?

Kimberly Lankford,

​Because Medicare decides how much to pay providers for covered services, if the provider agrees to the Medicare-approved amount, even if it is less than they usually charge, they’re accepting assignment.

A doctor who accepts assignment agrees to charge you no more than the amount Medicare has approved for that service. By comparison, a doctor who participates in Medicare but doesn’t accept assignment can potentially charge you up to 15 percent more than the Medicare-approved amount.

That’s why it’s important to ask if a provider accepts assignment before you receive care, even if they accept Medicare patients. If a doctor doesn’t accept assignment, you will pay more for that physician’s services compared with one who does.

AARP Membership — $12 for your first year when you sign up for Automatic Renewal

How much do I pay if my doctor accepts assignment?

If your doctor accepts assignment, you will usually pay 20 percent of the Medicare-approved amount for the service, called coinsurance, after you’ve paid the annual deductible. Because Medicare Part B covers doctor and outpatient services, your $240 deductible for Part B in 2024 applies before most coverage begins.

All providers who accept assignment must submit claims directly to Medicare, which pays 80 percent of the approved cost for the service and will bill you the remaining 20 percent. You can get some preventive services and screenings, such as mammograms and colonoscopies , without paying a deductible or coinsurance if the provider accepts assignment. 

What if my doctor doesn’t accept assignment?

A doctor who takes Medicare but doesn’t accept assignment can still treat Medicare patients but won’t always accept the Medicare-approved amount as payment in full.

This means they can charge you up to a maximum of 15 percent more than Medicare pays for the service you receive, called “balance billing.” In this case, you’re responsible for the additional charge, plus the regular 20 percent coinsurance, as your share of the cost.

How to cover the extra cost? If you have a Medicare supplement policy , better known as Medigap, it may cover the extra 15 percent, called Medicare Part B excess charges.

All Medigap policies cover Part B’s 20 percent coinsurance in full or in part. The F and G policies cover the 15 percent excess charges from doctors who don’t accept assignment, but Plan F is no longer available to new enrollees, only those eligible for Medicare before Jan. 1, 2020, even if they haven’t enrolled in Medicare yet. However, anyone who is enrolled in original Medicare can apply for Plan G.

Remember that Medigap policies only cover excess charges for doctors who accept Medicare but don’t accept assignment, and they won’t cover costs for doctors who opt out of Medicare entirely.

Good to know. A few states limit the amount of excess fees a doctor can charge Medicare patients. For example, Massachusetts and Ohio prohibit balance billing, requiring doctors who accept Medicare to take the Medicare-approved amount. New York limits excess charges to 5 percent over the Medicare-approved amount for most services, rather than 15 percent.

AARP NEWSLETTERS

%{ newsLetterPromoText  }%

%{ description }%

Privacy Policy

ARTICLE CONTINUES AFTER ADVERTISEMENT

How do I find doctors who accept assignment?

Before you start working with a new doctor, ask whether he or she accepts assignment. About 98 percent of providers billing Medicare are participating providers, which means they accept assignment on all Medicare claims, according to KFF.

You can get help finding doctors and other providers in your area who accept assignment by zip code using Medicare’s Physician Compare tool .

Those who accept assignment have this note under the name: “Charges the Medicare-approved amount (so you pay less out of pocket).” However, not all doctors who accept assignment are accepting new Medicare patients.

AARP® Vision Plans from VSP™

Exclusive vision insurance plans designed for members and their families

What does it mean if a doctor opts out of Medicare?

Doctors who opt out of Medicare can’t bill Medicare for services you receive. They also aren’t bound by Medicare’s limitations on charges.

In this case, you enter into a private contract with the provider and agree to pay the full bill. Be aware that neither Medicare nor your Medigap plan will reimburse you for these charges.

In 2023, only 1 percent of physicians who aren’t pediatricians opted out of the Medicare program, according to KFF. The percentage is larger for some specialties — 7.7 percent of psychiatrists and 4.2 percent of plastic and reconstructive surgeons have opted out of Medicare.

Keep in mind

These rules apply to original Medicare. Other factors determine costs if you choose to get coverage through a private Medicare Advantage plan . Most Medicare Advantage plans have provider networks, and they may charge more or not cover services from out-of-network providers.

Before choosing a Medicare Advantage plan, find out whether your chosen doctor or provider is covered and identify how much you’ll pay. You can use the Medicare Plan Finder to compare the Medicare Advantage plans and their out-of-pocket costs in your area.

Return to Medicare Q&A main page

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at  Kiplinger’s Personal Finance  and has written for  The Washington Post  and  Boston Globe . She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

Discover AARP Members Only Access

Already a Member? Login

More on Medicare

How Do I Create a Personal Online Medicare Account?

You can do a lot when you decide to look electronically

I Got a Medicare Summary Notice in the Mail. What Is It?

This statement shows what was billed, paid in past 3 months

Understanding Medicare’s Options: Parts A, B, C and D

Making sense of the alphabet soup of health care choices

Recommended for You

AARP Value & Member Benefits

Learn, earn and redeem points for rewards with our free loyalty program

AARP® Dental Insurance Plan administered by Delta Dental Insurance Company

Dental insurance plans for members and their families

The National Hearing Test

Members can take a free hearing test by phone

AARP® Staying Sharp®

Activities, recipes, challenges and more with full access to AARP Staying Sharp®

SAVE MONEY WITH THESE LIMITED-TIME OFFERS

What healthcare REITs mean for providers, patients

Steward Health Care's Chapter 11 bankruptcy filing is the latest example of the significant role real estate investment trusts play in healthcare.

REITs have served as a financial solution for providers and health systems, allowing them to broaden their networks without as hefty a capital investment.

Related article: KKR, Healthcare Realty Trust partner on acquisitions

Steward, for example, is the largest tenant of Medical Properties Trust, which bought Steward's real estate assets in 2016. The REIT, which also owns 10% of Steward, has approved $75 million in debtor-in-possession financing to help Steward maintain patient care while looking for operators for its hospitals.

Much like private equity's ownership of healthcare organizations , there are concerns about the potential cross-purposes of REITs in healthcare, since their goal of creating investor returns may run counter to the access and delivery of patient care.

Here's what to know about the growing role of real estate investment trusts in healthcare.

What is a REIT?

A real estate investment trust is an entity that owns, operates or otherwise financially supports a portfolio of commercial real estate properties.

The passage of the Real Estate Investment Trust Act in 1960 allowed everyday people, not just corporations, to invest in commercial real estate.

Many REITs are publicly traded, meaning the general public can invest in a REIT by buying shares outright or it can be part of another investment vehicle such as a mutual fund or a 401(k) retirement account. Nareit, an association for real estate investment trusts, estimates 170 million people, or 75% of U.S. households, either directly or indirectly own REIT stocks.

Generally, a REIT must pay out a minimum of 90% of its taxable income to shareholders annually in the form of dividends.

Why are healthcare REITs popular?

Healthcare players ranging from health systems to physician groups and skilled nursing facilities are looking to both free up capital and expand to serve an aging America in need of healthcare services in a variety of locations. Part of that growth comes from opening new facilities.

On the investor side of it, healthcare is considered far more recession-proof than, say, retail or commercial real estate so it is attractive because of the returns generated. 

Healthcare REITs own more than $2.5 trillion in industry assets, according to real estate services firm JLL.

What federal oversight is in place?

In November, the Centers for Medicare and Medicaid Services  finalized a rule  that requires nursing homes that accept Medicare or Medicaid to disclose owners and other affiliated businesses. The rule means they must disclose relationships with REITs or other entities that own property on which nursing homes stand even if they don't own or operate the facilities themselves.

The rule, which took effect in January, is an  effort to improve industry transparency  for consumers, following reports that facilities had lower staffing and care quality levels.

What healthcare properties are REITs buying?

Senior living facilities and medical offices each account for about a third of the properties in REITs, followed by skilled nursing facilities and life sciences-related facilities.

While the COVID-19 pandemic forced many nursing homes  to close, the need for those facilities remains so REITs view the properties as good investments, according to Tedd Flagg, a JLL senior marketing manager and member of its mergers and acquisitions and corporate advisory group.

Life sciences facilities are another area of interest due to the increased interest of private equity in biotech.

Who are the big players?

There are 16 publicly traded healthcare REITs. The three largest companies, by their number of properties, are Welltower, which owns senior housing, post-acute care and outpatient facilities; Ventas, whose portfolio includes senior living, skilled nursing facilities, health systems, outpatient facilities and office properties; and Healthpeak Properties, which focuses on outpatient and lab facilities. 

What are some of the latest moves by REITs?

In addition to its work with Steward, Medical Properties Trust last month sold five hospitals  in April to Ontario, California-based Prime Healthcare for $350 million. 

In March, Sila Realty Trust acquired five healthcare properties leased by Tenet Healthcare for $85.5 million, and CareTrust REIT acquired two properties from Altamonte Spring, Florida-based AdventHealth in August. 

Healthcare REITs also have started partnering with private equity firms. Healthcare Realty Trust formed a joint venture with global investment firm KKR   to acquire outpatient facilities. The REIT will invest 12 of its medical properties, valued at $382.5 million, into the venture. KKR will make an equity contribution valued at 80% along with another $600 million for future acquisitions. 

Related Articles

Send us a letter

Have an opinion about this story?  Click here to submit a Letter to the Editor , and we may publish it in print.

Daily Finance Newsletter: Sign up to receive daily news and data that has a direct impact on the business and financing of healthcare.

• Current News
• Safety & Quality
• Digital Health
• Care Delivery
• Digital Edition (Web Version)
• Layoff Tracker
• Sponsored Content: Vital Signs Blog
• From the Editor
• Nominate/Eligibility
• 100 Most Influential People
• 50 Most Influential Clinical Executives
• 40 Under 40
• Best Places to Work in Healthcare
• Healthcare Marketing Impact Awards
• Innovators Awards
• Diversity Leaders
• Women Leaders
• Digital Health Summit
• Leadership Symposium
• Social Determinants of Health Symposium
• Women Leaders in Healthcare Conference
• Best Places to Work Awards Gala
• Diversity Leaders Gala
• - Future of Staffing
• - Health Equity & Environmental Sustainability
• - Hospital of the Future
• - Financial Resiliency
• - Value Based Care
• - Looking Ahead to 2025
• Podcast - Beyond the Byline
• Sponsored Podcast - Healthcare Insider
• Sponsored Video Series - One on One
• Sponsored Video Series - Checking In with Dan Peres
• Data & Insights Home
• Hospital Financials
• Staffing & Compensation
• Quality & Safety
• Mergers & Acquisitions
• Skilled Nursing Facilities
• Data Archive
• Resource Guide: By the Numbers
• Data Points
• Newsletters
• People on the Move
• Reprints & Licensing
• Sponsored Content

Patient acuity tool on a medical-surgical unit

Use a tool for consistent, objective, and quantifiable patient assignments..

• Patient assignments can lead to dissatisfaction among nursing staff, especially when they’re not consistent, objective, and quantifiable.
• Dissatisfaction can create barriers to the adaptability and teamwork that are critical to good patient care.
• The patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations.

Patient assignments can lead to dissatisfaction among nursing staff, especially when they’re not consistent, objective, and quantifiable. This dissatisfaction can create barriers to the adaptability and teamwork that are so critical to good patient care.

In 2016, three RNs on a complex 23-bed medical-surgical unit at Durham VA Health Care System identified a recurring complaint by nursing staff that patient assignments were inconsistent and unequal. An average of five RNs and one charge nurse were assigned five patients per nurse per shift. The nursing assignment system included placing patients in one of two categories: “standard patient” or “involved care” patient. The problem was the subjectivity of these terms; they had no supporting evidence. The result was frustrated nurses, which prompted the unit to develop a process improvement project.

Standardizing handoff communication

The Bedside Mobility Assessment Tool 2.0

Hours per patient day: Understanding this key measure of productivity

Purpose and goals

We used evidence-based information to create an objective acuity tool to establish patient assignments. The tool uses both clinical patient characteristics and workload indicators to score patients from 1 to 4 based on acuity level. This approach gives nurses the power to score their patient, then report to the charge nurse so that RN assignments for the oncoming shift are quantifiable and equitable. It also gives them the opportunity to assess the level of patient safety risk.

The goals of the tool are to:

• increase nurse satisfaction with their patient assignment
• increase nurse perception of patient safety by assigning patients with high acuity scores equitably.

The patient acuity tool

Each patient is scored on a 1-to-4 scale (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) based on the clinical patient characteristics and the care involved (workload.) Each nurse scores his or her patients, based on acuity, for the upcoming shift and relays this information to the charge nurse, who then assigns patients before the shift change. The handoff report between RNs allows each to validate patients’ current acuity and care needs. (See Patient acuity tool .)

Methodology

Anecdotal reports by the RN staff and our observations prompted the collection of data from staff. Some of the staff comments about the current system included:

• “Why are my patient assignments so unfair?”
• “How will I care for all of my patients effectively?”
• “Involved care is a subjective term.”

We conducted a literature review and eventually combined two existing tools and restructured them to create our acuity tool. Before implementing the process improvement project, we used the newly created tool to assess the current average distribution of total acuity among nurse assignments, and we asked RNs to complete a 10-question survey to measure their satisfaction with patient assignments and perceptions of patient safety. We then taught the RNs how to use the tool and placed color-coded, laminated copies at every nursing computer.

The tool was pilot tested for 28 days. After the first 14 days, we conducted an audit to assess compliance, which revealed that average compliance among all four shifts was 35%. We then collected data on the average distribution of total acuity among nurse assignments. Progress e-mails were sent to staff, and individual follow-ups were held to promote compliance. At the end of the 28 days, we conducted another compliance audit, which revealed an average compliance among all four shifts of 77%, an increase of 220%.

At the end of the pilot study, we reviewed patient assignments before and after implementing the acuity tool to assess their equality, and we surveyed RNs about the two goals we set for the project: improve nurse satisfaction and increase nurse perception of patient safety.

Equality of patient assignments

To determine the equality of nurses’ assignments within a shift, the difference in total acuity between the highest and lowest scoring assignments was obtained. (See RN assignments using acuity tool .)

Before implementing the acuity tool, the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83 (using a scale of 1 = lowest acuity and 4 = highest acuity). After implementation, the average distribution of total acuity between highest and lowest nurse assignments was 3.06, a 36.6% improvement in equality and accuracy.

Goal 1: Improve nurse satisfaction

Three of the 10 questions in the nurse survey were aimed at nurse satisfaction, including RN perception of patient assignment equality, having input into making assignments, and frequency of feeling overwhelmed with patient assignments. The most significant change occurred with the question “Please rate how frequently you feel overwhelmed with your patient assignment.” Response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). According to the survey, the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.

Goal 2: Increase nurse perception of patient safety 

When asked to respond to the statement “I feel like patient safety is a concern when I accept my patient assignment,” RN staff chose from the following options: never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The weighted average was 3.38 pre-implementation and 3.21 post-implementation, a 5% improvement in RNs’ perception of patient safety. After reviewing the annual performance improvement data, we found no direct correlation between using the acuity tool and patient safety measurements (rate of falls, medication errors, and restraint use). However, by distributing high-acuity patients among nurses, this tool, used in conjunction with other current actions, can reduce the need for patient safety measures such as using sitters and frequent rounding.

We attributed many of the challenges faced during the implementation of this project to staff assignment changes during some 24-hour periods. Sometimes patient assignments changed every 4 hours because of differences in nurse shift length, which left the staff with no consistent communication between shifts. The charge nurse would also occasionally take a patient assignment when patient acuity was high and RN census was low, resulting in outliers in data.

Another challenge included RN staff changes during the pilot study, leading to gaps in education about proper use of the tool, decreased feedback, and less data in post-implementation than pre-implementation. As part of our sustainment plan, we’ll incorporate education on the tool in new staff orientation, adapt it to other medical-surgical units in the hospital, and continue quarterly audits to assess compliance.

Given the original concern by staff that assignments were unequal, one of the strengths of this acuity tool is that it allows nurses to become stakeholders in making patient assignments. In addition, it also gives the charge nurse an objective way to justify assignment rationale. The tool costs no money to implement and requires no special technology. In addition, it’s noninvasive to the unit’s workflow, easy to implement, and easily adapted to different units and their specific needs. We’ve also found that the tool enhances the shift-to-shift handoff report and that it can be used to assign patients based on nurse competence (novice nurses, expert nurses, etc.).

Striking a balance

The patient acuity tool addresses the important issue of unbalanced nurse-patient assignments and helps nurses influence decision-making in their organizations. Our research found that an objective patient acuity tool on a medical-surgical floor could increase assignment equality, improve nurse satisfaction, and improve nurse perception of patient safety. The tool is now being piloted on other units at this facility, and we’ve received consults from other facilities in the Veterans Affairs Health Care System.

Andrea Ingram is a medical-surgical certified nurse at the VA Health Care System in Durham, North Carolina. Jennifer Powell is a neonatal intensive care unit nurse at Novant Health Hemby Children’s Hospital in Charlotte, North Carolina.

Selected references

Chiulli KA, Thompson J, Reguin-Hartman KL. Development and implementation of a patient acuity tool for a medical-surgical unit . Academy of Medical-Surgical Nurses. 2014;23(2):1, 9-12.

Kidd M, Grove K, Kaiser M, Swoboda B, Taylor A. A new patient-acuity tool promotes equitable nurse-patient assignments . American Nurse Today. 2014;9(3):1-4.

24 Comments .

Hello, I am working on my DNP project and wondering if I could utilize the PAT here during my study citing it appropriately?

Thank you Nikki

would like to know more about this classification tool, is it still in use or has it been revised? can it be used without copywrite restrictions? is it electronically available

Yes, you can use it but must source the tool appropriately.

I am interested to know how to utilize this acuity tool. I have several nurses complain about assignments, this might be something that our unit could utilize to better assignments.

My name is Tijuana L Parker and we want to use your tool on our unit to see if we can balance the assignments better and improve nurse satisfaction.

Hi Mrs. Andrea Ingram, and Jennifer Powell,

I would like to ask if there is any educational material on how di you roll out your acuity tool.

Dear Mrs. Andrea Ingram, and Jennifer Powell

My name is Myriam Valdema, a DNP student. Thank you for such a fantastic study. I am writing my final project on a patient-acuity tool’s effect on job satisfaction in a medical-surgical Unit. We are currently using the block method to make assignments, and it is not working well for the nurses. With your permission, I would like to use the tool to provide better patient assignments while improving patients’ safety.

Sincerely, Myriam Valdema BSN, RN

Thank you for the great article Andrea Ingram and Jennifer Powell. I am writing to seek permission to reuse the tool for our tertiary hospital. Let me know the psychometric properties of the tool or Has it been tested for validity and reliability. Sincerely Dr.Asha Raj Sudha

Dear Mrs. Andrea Ingram, and Jennifer Powell, Thank you for a very intersting study. We are interested in implementing it in our hospital. May we ask : 1) Is it applicable to all types of patient population or restricted to medical surgical as the the title of the article suggests? 2) Has it been tested for validity and reliability and can be safely used to assess the patients acuity. 3) Has it been successfuly in other hospitals? 4) Is there a copyright if want to use?

We started a project on my unit about four years ago using EPIC to created a tool for our surgical trauma progressive care. Working with our EMR nurse team, we were able to customize the tool to fit our patient population. If you would like more information, please let me know.

Patrice, I would love to know how you utilized EPIC to create an acuity tool. I am currently working on finding or creating one for my department. I would love if you could reach out to me. My personal email is wiels1987 at gmail. Thank you.

Interesting article, thank you for acknowledging and taking action to help improve a system. It would be ideal to have a universal acutiy tool that all units can adapt to their speciality. I was wondering how you than use this tool to decide how many staff you require on the ward? If you have so many orange and red level patients, are you able to aquire more staff? Or are you only using this tool to allocate patients equitably between the 5 staff you have?

I was wondering if we would be able to reference the acuity tool in an EVB project we are doing?

This is an interesting article, but I think the use of quantitative measures such as means on ordinal scales is incorrect. First, the score (1, stable patient; 2, moderate-risk patient; 3, complex patient; 4, high-risk patient) is made to be ordinal, therefore, the interpretation “the average distribution of total acuity between highest and lowest nurse assignments for each shift was 4.83” is not appropriate and should not be used. The difference between “stable patient”, “moderate-risk patient” and “complex patient” are not equal. In other words, one cannot assume that the difference between responses is equidistant even though the numbers assigned to those responses are. The same interpretive problem is present for the question “Please rate how frequently you feel overwhelmed with your patient assignment”. The response options were never (1), rarely (2), sometimes (3), frequently (4), and every shift (5). The comment : “the weighted average of nurse satisfaction was 3.19 before implementing the acuity tool and 2.84 (11% improvement) after.”, is also incorrect. I would suggest reporting the percentage of each classes and the median (1). This would be transparent and avoid false interpretations if the answers were clustered at the high and low extremes.

Secondly, I understand the need to have an objective tool and I also chase this goal, but when I read the table “RN assignments using acuity tool”, I come to the conclusion that it is not at all objective and that the nurse’s classification is completely subjective. Either the tool needs to be less interpretation-free and have more quantitative criterias or the nurses need to have the same interpretation of each criteria before using the tool.

I want to thank you for your work as it is a great start and hope you continue to enhance this potentially powerful tool.

Vincent Morissette-Thomas, Statistician and Data Scientist

1. Sullivan, Gail M., and Anthony R. Artino Jr. “Analyzing and interpreting data from Likert-type scales.” Journal of graduate medical education 5.4 (2013): 541-542.

Nice article on acuity. Many years I developed numerous acuity systems from P.I.C.U., to ED and Psychiatric units.

I am interested in using a Patient Acuity tool for my DNP project. Can I use this tool? Thank you. Catherine Bell MSN RNC

Dear Mrs. Andrea Ingram, and Jennifer Powell, I am interested in using a Patient Acuity tool for my project. Can I use this tool? Thank you.

Thank you Great article. I was wanting to contact author about the possibility of using this tool.

I am writting in regards to “patient acuity tool on a medical surgical unit” I am currently connected with a regional hospital (government owned) here in the philippines with a bed capacity of 800 but in reality it is way more than that since we are not allowed to refuse a patient since we are the end refferal hospital in our region.. my hospital have not adapted any tool on patient assignment that most often led to nurse job unsatisfaction and burnt out. And i think your study will be of great help. But before my hospital can adapt this, it has to be grounded with a study and so I will be making a study on this and would like to use also your survey with some revisions that is applicable to us if you could allow me. Thank you in advance.

Thank you all for the responses to the article! I am sorry it has taken me this long to respond, but I would love to provide the survey used. Unfortunately, I’m only able to find 6 of the 10 questions (my account used for the online survey was deleted) but I hope these questions help you.

Re: Liz Doll, I’m so glad you would find this tool helpful. You are more than welcome to adapt our tool to fit your patient population. I hope it works out well for your staff!

1. How long have you been a nurse? 2. How long have you been a nurse on 6A? (the name of our unit) 3. In my opinion, I feel that patient assignments are equal between nursing staff. (Strongly agree, agree, neutral, disagree, strongly disagree.) 4. In my opinion, I feel like I have input into making the nursing assignments. (Strongly agree, agree, neutral, disagree, strongly disagree.) 5. Please rate how frequently you feel overwhelmed with your patient assignment. (Frequently, sometimes, rarely, never.) 6. I feel like patient safety is a concern when I accept my patient assignment. (Every shift, frequently, sometimes, rarely, never.)

Loved this study and was wondering if there’d be a way to get a copy of the survey used? Thank you!

Is there a way to get a copy of the survey questions used? This is a great article!

Thank you for this insightful article. Our hospital is expanding beds and we have been using this tool to ensure our new units are properly staffed. With your permission, our team would like to make slight modifications to this tool to better fit our unique patient population. Please let me know your thoughts!

I am writing in regards to “Patient acuity tool on a medical-surgical unit” (Morrow and Powell, 2018). I believe patient acuity is a critical aspect to take into consideration when looking at staffing and nursing assignments. I agree with method the article used, creating a tool to score patient acuity. It is important to have an objective way to determine the acuity and fairly assign patients to a nurse. Having a balanced assignment benefits not only nurses by decreasing their workload, but also extends to the patients by giving them better outcomes. As a bedside nurse I have experienced overwhelming, unbalanced patient assignments. Being stretched thin forces me to be more task-oriented rather than patient centered, as I would prefer. Several months ago the unit I work for started utilizing a tool similar to the one mentioned in the article. By giving us an objective way to rate the acuity of a patient it lead to more balanced the assignments. It gave us more of a say in the assignments, the charge nurses ask us our opinions on our patient group and if they need to be separated for the next shift. This makes us feel as though we have a voice and give the charge nurse an objective way to fairly make assignments (Morrow, 2018). Overall, RNs who rated their assignments as appropriate were more likely to be satisfied with their jobs, intend to stay on their current units, and deliver quality care to patients than those who rated their assignments as inappropriate. Registered nurses who said that their assignments were appropriate are more likely have higher job satisfaction and deliver higher quality care to patients as opposed to nurses who said their patient assignments were inappropriate and unbalanced (Choi, 2018). I find that in my own practice, a balanced mix of acuity within an assignment group I am able to spend more face-to-face time with each patient as opposed to having a group of patients who are all considered high acuity. Utilizing a patient classification system is a low cost tool that nurse leaders can ensure that nurses are receiving equal assignments.

Sincerely, Carrie Young, RN

References Choi, J (2018). Registered Nurse Perception of Patient Assignment Linking to Working Conditions and Outcomes. Journal of Nursing Scholarship, 50(5). Retrieved from https://doi-org.liblink.uncw . edu/10.1111/jnu.12418

Morrow, A. & Powell, J. (2018). Patient acuity tool on a medical-surgical unit. American Nurse Today, 13(4). Retrieved from https://www.myamericannurse.com/patient-acuity-meidcal-surgical-unit

Comments are closed.

NurseLine Newsletter

• First Name *
• Last Name *
• Hidden Referrer

*By submitting your e-mail, you are opting in to receiving information from Healthcom Media and Affiliates. The details, including your email address/mobile number, may be used to keep you informed about future products and services.

Test Your Knowledge

Recent posts.

Knowledge of intravascular determination

Why Mentorship?

Virtual reality: Treating pain and anxiety

What is a healthy nurse?

Broken trust

Diabetes innovations and access to care

Breaking barriers: Nursing education in a wheelchair

Supporting the multi-generational nursing workforce

Vital practitioners

From data to action

Connecting theory and practice

Effective clinical learning for nursing students

Nurse safety in the era of open notes

Collaboration: The key to patient care success

Human touch

How bucket lists can help cancer patients and their loved ones enjoy life and prepare for death

Analysis How bucket lists can help cancer patients and their loved ones enjoy life and prepare for death

In the 2007 film The Bucket List , Jack Nicholson and Morgan Freeman play two main characters who respond to their terminal cancer diagnoses by rejecting experimental treatment. Instead, they go on a range of energetic, overseas escapades.

Since then, the term "bucket list" — a list of experiences or achievements to complete before you "kick the bucket" or die — has become common.

You can read articles listing the seven cities you must visit before you die or the 100 Australian bucket-list travel experiences .

But there is a more serious side to the idea behind bucket lists. One of the key forms of suffering at the end of life is regret for things left unsaid or undone. So bucket lists can serve as a form of insurance against this potential regret.

The bucket-list search for adventure, memories and meaning takes on a life of its own with a diagnosis of life-limiting illness.

In a study published this week , we spoke to 54 people living with cancer, and 28 of their friends and family. For many, a key bucket list item was travel.

Why is travel so important?

There are lots of reasons why travel plays such a central role in our ideas about a "life well-lived". Travel is often linked to important life transitions : the youthful gap year, the journey to self-discovery in the 2010 film Eat Pray Love , or the popular figure of the "grey nomad" .

The significance of travel is not merely in the destination, nor even in the journey. For many people, planning the travel is just as important. A cancer diagnosis affects people's sense of control over their future, throwing into question their ability to write their own life story or plan their travel dreams.

Mark, the recently retired husband of a woman with cancer, told us about their stalled travel plans:

"We're just in that part of our lives where we were going to jump in the caravan and do the big trip and all this sort of thing, and now [our plans are] on blocks in the shed."

For others, a cancer diagnosis brought an urgent need to "tick things off" their bucket list. Asha, a woman living with breast cancer, told us she'd always been driven to "get things done" but the cancer diagnosis made this worse:

"So, I had to do all the travel, I had to empty my bucket list now, which has kind of driven my partner round the bend."

People's travel dreams ranged from whale watching in Queensland to seeing polar bears in the Arctic, and from driving a caravan across the Nullarbor Plain to skiing in Switzerland.

Nadia, who was 38-years-old when we spoke to her, said travelling with her family had made important memories and given her a sense of vitality, despite her health struggles. She told us how being diagnosed with cancer had given her the chance to live her life at a younger age, rather than waiting for retirement:

"In the last three years, I think I've lived more than a lot of 80-year-olds."

But travel is expensive

Of course, travel is expensive. It's not by chance Nicholson's character in The Bucket List is a billionaire.

Some people we spoke to had emptied their savings, assuming they would no longer need to provide for aged care or retirement. Others had used insurance payouts or charity to make their bucket-list dreams come true.

But not everyone can do this. Jim, a 60-year-old whose wife had been diagnosed with cancer, told us:

"We've actually bought a new car and [been] talking about getting a new caravan … But I've got to work. It'd be nice if there was a little money tree out the back but never mind."

Not everyone's bucket list items were expensive. Some chose to spend more time with loved ones, take up a new hobby or get a pet.

Our study showed making plans to tick items off a list can give people a sense of self-determination and hope for the future. It was a way of exerting control in the face of an illness that can leave people feeling powerless. Asha said:

"This disease is not going to control me. I am not going to sit still and do nothing. I want to go travel."

Something we 'ought' to do?

Bucket lists are also a symptom of a broader culture that emphasises conspicuous consumption and productivity, even into the end of life.

Indeed, people told us travelling could be exhausting, expensive and stressful, especially when they're also living with the symptoms and side effects of treatment. Nevertheless, they felt travel was something they "ought" to do.

Travel can be deeply meaningful, as our study found. But a life well-lived need not be extravagant or adventurous. Finding what is meaningful is a deeply personal journey.

Leah Williams Veazey, Alex Broom and Katherine Kenny are sociologists based at the Sydney Centre for Healthy Societies at The University of Sydney.  This piece first appeared on The Conversation .

• X (formerly Twitter)

Related Stories

What a cancer nurse and psychologist say about sharing a diagnosis with others.

Before Kylie goes deaf, there's one more sound she'd really like to hear

'Seven times down, eight times up': When life is hard, how do we go on?

• Community and Society
• Death and Dying
• Travel and Tourism (Lifestyle and Leisure)

Patients face longer trips, less access to health care after Walmart shuts clinics

For rural and lower-income Americans, staying healthy will become more time-consuming, experts say, with longer drives and wait times for doctors following Walmart's decision last month to exit the primary care business.

Walmart announced on April 30 that it would close all 51 Walmart Health centers in five states and shut down its virtual health care service because it was “not a sustainable business model.”

The move marked a sudden shift for the giant retailer, which had said the previous month that it planned to expand its virtual 24/7 health care – which includes video, chat and calls – and its brick-and-mortar health centers, which were open during the same hours and days as its stores and staffed by primary care physicians and licensed nurse practitioners.

The shift also reflects bigger economic challenges in health care, which is struggling with low government reimbursements for primary care, a shortage of nurses and doctors , and soaring costs for supplies and labor, experts said.

What happens to those Americans now?

For patients in rural areas or areas with limited resources served by Walmart, the closings will mean difficulty finding health care in the near term and traveling longer distances once they do, said Hal Andrews, chief executive of healthcare consulting firm Trilliant Health.

Protect your assets: Best high-yield savings accounts of 2023

"People will have to go back to driving to a big city," Andrews said. "Going to the doctor will take an entire day. We’re going backward.”

When Walmart entered primary care in 2019, it said it could provide many Americans with close and easy access to primary care, including dental, vision and mental health since 90% of Americans lived within 10 miles of a Walmart store.

However, Walmart found that affordable care was not affordable for providers, even for a retail giant known for squeezing out a profit from low-margin businesses like groceries.

"Primary care margins are small, similar to grocery margins," Andrews said.

It was a "difficult decision, and like others, the challenging reimbursement environment and escalating operating costs create a lack of profitability that make the care business unsustainable for us at this time," Walmart said.

Those economics lay bare the challenges of running a health care business, said Brian Marks, University of New Haven senior lecturer of economics and business analytics. “It’s problematic and suggests we need to reexamine the primary health care delivery system.”

Only the company's vision centers and pharmacies, which weren't part of Walmart Health, will now stay open, Walmart said.

Who’s most directly affected by Walmart Health’s closing?

Walmart ran most of the centers in rural, low-income and underserved communities in Arkansas, Florida, Georgia, Illinois and Texas. These areas will suffer the most from the closings, Trilliant's Andrews said.

People who came into the clinics often had not seen a primary care physician in two or three years or a dentist in five years, Marcus Osborne, Walmart’s former vice president of health and wellness transformation, told CNN in 2020 . Some patients saw a mental health counselor for the first time.

Closings: Walmart will close all 51 of its health centers: See full list of locations

If Walmart can’t make it, who can?

Even Walmart, with its financial might, couldn’t attract enough health care workers amid a labor shortage, or find a way to make a profit by providing convenient, affordable primary care, experts said.

“It’s a terrible sign that Walmart, the top Fortune 500 company, can’t or decided not to” continue, Andrews said.

Other contenders in retail primary care have struggled too.

Walgreens said last month it would close 160 VillageMD clinics across the country, and Amazon in February announced job cuts at its One Medical primary care and Amazon Pharmacy units.

CVS, meanwhile, said it’s expanding its Oak Street Health clinics specializing in primary care for seniors, though it closed some of its MinuteClinics for nearly all ages earlier this year.

Why Walmart Health closed, and others may struggle

All these companies face similar financial hurdles that will likely lead to consolidation in care clinics, said Web Golinkin, a former health care CEO and author of "Here Be Dragons: One Man’s Quest to Make Healthcare More Accessible and Affordable."

“We’re flashing yellow lights here,” he said.

Where will Americans go for primary care?

No one can predict the future, but many experts believe virtual care, or telehealth, will become a larger part of care.

Telehealth may still be a financial struggle for companies, some warn. Walmart Health encompassed brick-and-mortar clinics and telehealth, but the company closed both, they noted.

During the pandemic , Americans were pushed toward virtual care, and “it will be part of health care forever, said Michael Botta, co-founder of Sesame, a health care marketplace connecting patients with providers.

Sesame, a Costco partner, offers discounted 24/7 virtual primary and mental health care. It also offers checkups with standard labs and in-person visits.

Sesame says it doesn’t accept insurance so it doesn't rely on reimbursements and can offer patients low, transparent prices. Patients can pay per visit with an individual provider or join its subscription model for ongoing care.

Andrews is a telehealth skeptic. For mental health, telehealth works because people feel comfortable speaking at a distance, but most patients prefer personal interaction in a physical exam, he said.

As a business, telehealth may prove challenging as well.  

“Other than an iPhone and wifi, there are no barriers to entry,” Andrews said. “No one can build a competitive moat around it.”

Instead, he sees primary care shifting back to offices and hospitals, with immediate care clinics available in densely populated areas where the economics are better.

None of that helps rural, low-income, underserved communities Walmart left behind, he said.

To ease the ongoing health care worker shortage, the University of New Haven's Marks sees regulations changing to allow non-physicians like nurse practitioners and physician assistants to provide more services.

But until all this happens, Marks said get used to “increased wait times.”

Medora Lee is a money, markets, and personal finance reporter at USA TODAY. You can reach her at [email protected] and subscribe to our free Daily Money newsletter for personal finance tips and business news every Monday through Friday morning.   

• Skip to main content
• Keyboard shortcuts for audio player

Goats and Soda

• Infectious Disease
• Development
• Women & Girls
• Coronavirus FAQ

Middle East crisis — explained

U.s. medical volunteers in rafah hospital say they've never seen a worse health crisis.

A scene at a hospital in Rafah, where the war has had a devastating impact on the ability of health workers to care for patients. Courtesy Ammar Ghanem hide caption

A scene at a hospital in Rafah, where the war has had a devastating impact on the ability of health workers to care for patients.

Editor's note: This story contains graphic descriptions of injuries.

AMMAN, Jordan — At one of the last functioning hospitals in Rafah, scenes of horror are conveyed in clinical descriptions as U.S. medical volunteers grapple with the effects of Israeli military operations and border closures after seven months of war in Gaza.

"They tried to suture up the hole in the heart — they couldn't," Dr. Usman Shah, from California, explains to Dr. Ammar Ghanem about a patient wounded in an explosion. Ghanem, a vice president of the Syrian American Medical Society, is overseeing the intensive care unit and made a video on Friday of his conversation with Shah.

"There was too much blood loss – the heart cavity, they tried to massage it but the heart cavity was empty," Shah says.

The two are members of a team of U.S. and U.S.-trained doctors who arrived in Rafah 10 days ago as part of a medical mission organized by the Palestinian American Medical Association . Now, nearing the end of the mission, with Israel closing the main border crossing, they are unable to leave.

In the video recorded Friday by Ghanem, Shah tells him about the other two patients who arrived that morning with non-survivable injuries.

Shah, dressed in blue scrubs, relates in an even voice how the jaw of one of the patients crumbled under his hand when he touched him. In the only visible sign of distress, he massages his temple and briefly closes his eyes as he tells the story.

Ghanem says conditions have worsened considerably since the border closure on May 7, with many of the local physicians and nurses unable to come to work because they have had to evacuate their families.

'Prioritizing patient lives'

Most of the doctors and nurses on the mission are experienced conflict zone volunteers. But Ghanem says they have never seen anything like this.

"Unfortunately here I have to prioritize patient lives. When I say 'prioritizing patient lives' I mean I know that term but I never used it before until I came here," he said in an interview with NPR by video call from Rafah.

The benign-sounding term refers to deciding whom to stop treating and let die in order to divert resources to those with a better chance of surviving.

In one of two videos sent to NPR from the hospital Ghanem points out to a colleague one of his most difficult cases – an 18-year-old woman with a skull fracture so severe that brain material was visible. He said they did not have drugs strong enough to keep her sedated.

He said they stopped treatment for a woman suffering from acute pancreatitis after two days because she required continued oxygen that might support several other patients.

"So you see how sad this is?" he said in the interview . "I mean this patient is only like about 60 years old. We will not do this in the U.S. as you know, but this time of war and lack of resources that we are forced to do this."

Ghanem, who did not want the hospital identified for security reasons, estimated that two to three patients a day die in the intensive care unit because of lack of supplies or equipment.

A lack of essential supplies

Part of the problem is that items critical for hospitals are banned by Israel which says they can be used by Hamas for military purposes. The list of items it considers dual-use include some water disinfection materials.

Caring for a patient at a hospital in Rafah. Needed supplies are hard to obtain due to delays caused by the Israeli military. Courtesy Ammar Ghanem hide caption

Caring for a patient at a hospital in Rafah. Needed supplies are hard to obtain due to delays caused by the Israeli military.

The list does not cover all items that are reportedly banned. Save the Children has said it has had shipments rejected by Israel because they contained sleeping bags with zippers. An Israeli legal center, Geisha, has compiled a list of items that have been reported by organizations to have been rejected, including fishing rods and plastic sheets for tents.

The result, according to the U.N. and international aid agencies, is long delays and a spiraling crisis in humanitarian aid.

After the killing of seven workers in Gaza from the U.S.-based World Central Kitchen last month, Israel, under U.S. pressure, pledged to allow in more aid, improve coordination and to safeguard humanitarian staff.

A Palestinian medic cares for babies born preterm at a hospital in Rafah in the southern Gaza Strip on April 24. AFP via Getty Images hide caption

A Palestinian medic cares for babies born preterm at a hospital in Rafah in the southern Gaza Strip on April 24.

A statement issued this week by seven major international aid organizations, including Save the Children and Care, said those pledges have not been fulfilled.

"Humanitarian actors see no significant improvement from Israeli authorities in addressing the dire challenges to prevent life-saving aid for Gaza's 2.3 million residents," the statement read.

Israel denies that it holds up aid.

International aid and medical workers who were either in Rafah or who had recently left, warned at a press briefing this week that the damage to Gaza infrastructure, lack of clean water, ongoing attacks and increasing starvation had brought humanitarian operations to the brink of collapse.

Israel has issued evacuation orders to sectors of Rafah, where more than 1.3 million people are crammed in near the Egyptian border. But for many there is no where to go.

Ghada al-Haddad, a Gaza-based communications officer for Oxfam , said families were pitching makeshift tents on sidewalks and in graveyards. She said others had moved to the beach, where there is no clean water and no sanitation.

Oxford professor Dr. Nick Maynard, a surgeon from England who traveled to Gaza three times on medical missions since the start of the war, said most of his time over Christmas was spent operating on major explosive injuries to the chest and abdomen. He said on his last trip this month that complications due to malnutrition in trauma cases had increased.

"I operated on many patients in the last two weeks who had awful complications from their abdominal surgery related to inadequate nutrition and particularly those with the abdominal wall breaking down," he said. "Literally their intestines end up hanging outside."

He said the hospitals lacked even colostomy bags along with materials to manage wounds and provide nutritional support.

Maynard said two of his patients, girls age 16 and 18, had survivable injuries but died last week as a direct result of malnutrition contributing to their deaths.

"We will see more of that in the coming months," he predicted

"We're at a tipping point right now," said Dr. John Kahler, co-founder of MedGlobal , a U.S.-based medical aid organization. He said Palestinian children before the war were getting only about 80% of the calories they needed. Now, seven months into the war, the effects of consistent deprivation are showing.

"It's at that time that the immunological system begins to break down," he said. "It's at that time where infections and complications of malnutrition will start."

Desperate for fuel

Aid officials said particularly alarming is the lack of fuel being allowed in. Most of Gaza's infrastructure has been destroyed and Israel has so far allowed fuel trucks to enter only through the main Rafah border crossing. That. crossing has now been closed since the beginning of the week.

"The whole aid operation runs on fuel," said Jeremy Konyndyk, president of Refugees International . "That means water can't be pumped, lights can't be kept on in hospitals, vehicles cannot distribute aid. So if the fuel is cut off the aid operation collapses, and it collapses quickly."

The Israeli military on Friday in an apparent response to the concerns said it had transferred more than 52,000 gallons of fuel to be made available to international organizations in Gaza through Kerem Shalom crossing into southern Gaza.

The head of the U.N.'s relief operations, Andrea De Domenico, told the French press agency AFP that amount of fuel was needed each day to maintain operations.

White House national security spokesman John Kirby on Friday said the U.S. wants the Rafah crossing, the only one able to handle large numbers of fuel trucks, opened immediately.

"Every day that that crossing is not available and usable for humanitarian assistance, there's going to be more suffering, and that's of deep concern to us," he told reporters. "And so once again, we urge the Israelis to open up that crossing to humanitarian assistance immediately, that aid is desperately needed."

At the Rafah hospital on Thursday, Monica Johnston, a burn nurse from Portland, Ore., was back at the ICU, only partially recovered from a gastrointestinal infection that left her dehydrated, dizzy and nauseous.

One of her patients was a 7-year-old boy with burns over 80% of his body.

"We're running out of pain medicine, running out of blood pressure medicine. So we cannot keep these people alive or comfortable. It's absolutely horrifying what we're seeing here," she said.

Johnston said everyone was desperately hoping for a cease-fire. (Israel says it is rejecting a sustained ceasefire because it needs to eliminate Hamas's military capability.)

"[A ceasefire]s will enable us to finish our mission, enable new help to come in, new supplies to come in, and eventually enable our safe return home," she said.

• Health Care