Abstract
While home health agencies (HHAs) can seek accreditation to recognize their quality of service, it is unknown whether agencies with accreditation perform better in providing care than those without accreditation. Using 5-year data from national data sources, the aims of this study were: 1) to depict characteristics of HHAs with and without accreditation; and 2) to examine the relationship between accreditation status and HHA performance on quality-of-care metrics. This study analyzed 7,697 agencies in the US and found that 1) agencies that were for-profit, urban, not-hospital-affiliated, single-branch, Medicare enrolled only, and without hospice program were more likely to have accreditation; and 2) overall, accredited agencies performed better on the three commonly used quality indicators, timely initiation of care, hospitalization, and emergency department visit, though not all the observed differences were substantial in absolute value. Our results provide unique empirical information to agencies considering seeking accreditation.
Keywords: home health, quality of care, accreditation, patient outcomes, hospitalization
Introduction
Along with the rapid growth in the number of “Aging in Place” older adults seeking health care at home, there is a growing concern for the quality of home health care provided to millions of homebound Americans.1 Indeed, the population of homebound older adults served by home health care is not only growing rapidly in size, it is also growing in complexity and diversity.2,3 Home health care is provided at the client’s home and includes a variety of skilled care services from interdisciplinary health care professionals, consisting of nurses (the primary home health care provider), physical and occupational therapists, speech-language therapists, and other medical and social services providers. In addition to skilled home health care, eligible clients may also receive care and assistance from home health aides. Home health care is one of the fastest growing health care sectors in the United States. It is also the most frequently used form of home and community-based services by homebound Americans, particularly those with physical and cognitive impairment.4–6 In 2018, over 5 million Medicare beneficiaries were serviced by over 11000 home health agencies nationwide, including approximately 49% accredited agencies.7,8
Similar to hospital accreditation from organizations such as the Joint Commission in recognition of excellence of hospital care, accreditation is also available to recognize home health agencies’ excellence in providing home health care, though it is less known. Currently, home health agencies can seek accreditation from three organizations: the Joint Commission (JC), Accreditation Commission for Health Care (ACHC), and Community Health Accreditation Program (CHAP). Of those three accrediting organizations, CHAP was established in 1965 as a collaboration between the American Public Health Association and the National League for Nursing, and is the first organization to provide accreditation to home care agencies in the United States.9 ACHC was founded in 1986 as the North Carolina Accreditation Commission for In-Home Aide Services” and formally accredited their first Medicare-certified home health agency in 1994.10 The JC’s Home Care Accreditation program was established in 1988 and has since accredited over 6000 programs in the United States.11
Home health agencies seek accreditation from those organizations to assess their level of performance relative to established standards. While the overall goal of these home health agency accreditation programs, which is to recognize the excellence of home health care, stays the same, there are some variations in the specific standards and criteria used by each accrediting organization, and the accreditation standards and criteria are often only available for purchase. For example, standards of excellence from CHAP are organized into three macro areas containing a total of 10 micro areas: patient-center care (three micro areas), safe care delivery (two micro areas), and sustainable organizational structure (five micro areas).12 Standards of excellence from ACHC are organized around each type of the services provided, such as skilled nursing services, physical therapy services, home health aide services, etc.13 Beyond recognition of excellence of care, receiving accreditation is an effective way for home health agencies to demonstrate and market the excellence of their services to the public.
Given the growing role of home health care in serving homebound Americans, there is also increasing regulatory scrutiny of home health care quality.14–16 Surprisingly, though home health agency accreditation has existed for decades, there is no research that has examined the extent to which home health agency accreditation status is in alignment (or misalignment) with agencies’ performance on national quality indicators. The purpose of this study was twofold: 1) to compare the characteristics of home health agencies with and without accreditation for the excellence of their services; and 2) to examine the relationship between accreditation status and performance on care quality of home health agencies over time. Findings from this study will shed light on the relationship between accreditation and quality performance of home health agencies. These findings can help inform clients’ decision-making when seeking home health care and provide important insights for agencies to optimize approaches in achieving excellence of home health care.
Methods
Study Design, Data Source, and Sample
This is a longitudinal cohort study using five years (2015–2019) of data from two national sources: the Centers for Medicare and Medicaid Services (CMS) Home Health Compare Program and Providers of Services file (POS).8,14 The Home Health Compare program was first developed by CMS in 2003 as a mechanism of publicly reporting quality of care data for Medicare-certified home health agencies in the United States. Home Health Compare data includes both process and outcome measures based on claims and patient assessment data to reflect quality performance of home health agencies. The selection of specific quality measures/indicators for the Home Health Compare Program is informed by ongoing data analysis and stakeholder input and slightly varies over time. Consequently, while some quality measures remain constant, some quality measures are modified, added, or removed over time and thus are not suitable for longitudinal study.
The POS file contains characteristics of Medicare-approved healthcare facilities, including Medicare-certified home health agencies. POS data are collected through the CMS Regional Offices and updated on a quarterly basis. Home health agency characteristics from POS file include location, type of Medicare services provided, affiliation status, and accreditation status, among other information.
For this study, a home health agency was included if it had 1) five years of data (2015–2019) for at least one of the three quality of care measures of interest in the Home Health Compare dataset, timely initiation of care, hospitalization rate, and emergency department visit rate; 2) complete information of accreditation status for each of the 5 years in the POS dataset; and 3) complete organizational characteristics at baseline year (2015) in the POS dataset. After applying these criteria, 7,697 home health agencies were included in the final analysis. Of these agencies, 7,595 had complete data on timely initiation of care, 6,452 had complete data on hospitalizations, and 6,450 had complete data on emergency department visits for the 2015–2019 period.
Measures
Home health care quality measures.
For this study, we used three quality of care indicators from the Home Health Compare dataset: timely initiation of care, hospitalization, and emergency department (ED) visits. We chose these three indicators because 1) they were consistently reported within the Home Health Compare dataset and 2) they reflected quality of care from both care process (timely initiation of care) and outcomes (hospitalization and ED visits) perspectives.14 In addition, the two outcomes measures included here were also in well alignment in the goals of home health care, which was to keep patients in home and community as long as possible and avoid unnecessary acute care utilizations (e.g., hospital and/or emergency care). These three indicators therefore provided good measures of quality of home health care over time. In the Home Health Compare program, a home health agency’s timely initiation of care rate is calculated as the percentage of client cases where care was started or resumed either on the physician-ordered date or within two days of referral or client discharge where no physician order was provided. Hospitalization rate is defined as the percentage of home health stays over a 12-month period where the client was admitted or re-admitted to the hospital within 60 days of start of care. ED visit rate is similarly defined as the percentage of home health stays over a 12-month period where the client required an ED visit but was not admitted to the hospital within 60 days of start of home health care. These measures were risk-adjusted using predictive models that were adjusted for differences in patient characteristics across agencies.17
Accreditation status.
Information related to accreditation status of a home health agency is from the POS dataset. An agency’s accreditation status is captured as either accredited (yes) or not accredited (no). Agencies are classified as accredited if they are accredited by any of the organizations that providing accreditation to home health agencies: The Joint Commission, Community Health Accreditation Partner, or Accreditation Commission for Health Care.
Covariates.
In addition to accreditation status, multiple home health agency characteristics were extracted from the POS dataset and included as potential covariates in the analysis. These characteristics were selected based on previous research that demonstrated an association between these characteristic and home health care quality.18–20 Included covariate organizational characteristics were geographic location (urban/rural), ownership (non-profit, for profit, or government), affiliation with a hospital (yes/no), CMS program enrollment (Medicare only or both Medicare and Medicaid), agency size (single agency vs multiple branches). All organizational characteristics were extracted for the baseline year of 2015 for analysis.
Data Analysis
For this study, the unit of analysis was the home health agency. Descriptive analysis was performed to describe baseline characteristics of the HHAs, including accreditation status. We then described differences in home health agency characteristics by accreditation status at baseline year, which was followed by a description of agencies’ changes in accreditation status over time. We further described the quality-of-care measures (timely start of care rate, hospitalization rate, and ED visit rate) by accreditation status and other agency characteristics. Graphs were also used to visually present trends in quality of home health care over time by agency accreditation status. Finally, to understand the relationship of quality of care with agency accreditation status (Model 1) and changes in accreditation status (Model 2), we employed generalized linear regression when controlling for agency characteristics and considering clustering of repeated measures within each agency. Given the longitudinal nature of our data, a variable indicating the time/year was included in the regressions. All statistical analyses were performed using StataSE version 17.0 (StataCorp LP) with an established alpha level of .05.
Results
Table 1 provides detailed information regarding baseline characteristics of home health agencies included in this study. At baseline year (2015), the majority of study agencies were unaccredited (63%), for-profit (77%), not affiliated with hospital (90.2%), without branches (82.4%), located in urban areas (80.5%), and participated in both Medicare and Medicaid services (78.8%). Among those agencies that were accredited, 42.9% received accreditation through The Joint Commission, 42.4% through CHAP, and 14.7% through ACHC.
Table 1.
Home Health Agency Characteristics at Baseline Year (2015), Overall and by Baseline Accreditation Status
| Characteristic | N | % | Accredited N (%) | Not Accredited N (%) |
|---|---|---|---|---|
|
| ||||
| Accreditation Status | ||||
| Accredited | 2852 | 37.05% | -- | -- |
| Not accredited | 4845 | 62.95% | -- | -- |
| Ownership Type | ||||
| For profit | 5926 | 76.99% | 2512 (88.08%) | 3414 (70.46%) |
| Non-profit | 1415 | 18.38% | 283 (9.92%) | 1132 (23.36%) |
| Government | 356 | 4.63% | 57 (2.00%) | 299 (6.17%) |
| Location | ||||
| Urban | 6194 | 80.47% | 2603 (91.27%) | 3591 (74.12%) |
| Rural | 1503 | 19.53% | 249 (8.73%) | 1254 (25.88%) |
| Agency Affiliation | ||||
| Hospital-based | 758 | 9.85% | 119 (4.17%) | 639 (13.19%) |
| Not hospital-based | 6939 | 90.15% | 2733 (95.83%) | 4206 (86.81%) |
| Agency Size | ||||
| Single agency | 6344 | 82.42% | 2607 (91.41%) | 3737 (77.13%) |
| Multiple branch agency | 1353 | 17.58% | 245 (8.59%) | 1108 (22.87%) |
| CMS Program Participation | ||||
| Medicare only | 1630 | 21.18% | 735 (25.77%) | 895 (18.47%) |
| Both Medicare and Medicaid | 6067 | 78.82% | 2117 (74.23%) | 3950 (81.53%) |
| Hospice care program | ||||
| Provide | 587 | 7.63% | 119 (4.17%) | 468 (9.66%) |
| Not provide | 7110 | 92.37% | 2733 (95.83%) | 4377 (90.34%) |
CMS, Centers for Medicare and Medicaid Services
There was a higher proportion of agencies that were for-profit, urban, not-hospital-affiliated, single-branch, Medicare enrolled only, and without hospice program among accredited agencies, compared to not-accredited agencies (Table 1).
Table 2 shows the distribution of home health care quality by agency characteristics for the baseline year of 2015. Accredited agencies had lower rates of hospitalization (accredited, 15.4%; non-accredited, 16.1%) and ED visits (accredited, 11.6%; non-accredited, 12.9%), compared to non-accredited agencies. However, accredited agencies had slightly lower rate of timely initiation of care than non-accredited agencies (accredited, 91.2%; non-accredited, 91.9%). In addition, home health agencies that were for profit, in urban areas, not hospital affiliated, and without branches performed better on hospitalization and ED visits (lower hospitalization rate and ED visit rate). At the same time, those agencies performed worse (lower rate) on timely initiation of care.
Table 2.
Quality of Home Health Care by Agency Characteristics at Baseline Year (2015)
| Timely imitation of care rate (n=7595) | Hospitalization rate (n=6452) | ED visit rate (n=6450) | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| Mean | SD | Mean | SD | Mean | SD | |
|
| ||||||
| Accreditation Status | ||||||
| Accredited | 91.16 | 8.76 | 15.43 | 4.01 | 11.56 | 4.02 |
| Not Accredited | 91.87 | 7.33 | 16.10 | 3.56 | 12.94 | 3.79 |
| Ownership Type | ||||||
| For Profit | 91.51 | 8.08 | 15.65 | 3.79 | 12.14 | 3.99 |
| Non-profit | 91.98 | 7.18 | 16.51 | 3.39 | 13.02 | 3.29 |
| Government | 91.73 | 7.43 | 16.38 | 4.10 | 14.67 | 4.54 |
| Location | ||||||
| Urban | 91.41 | 8.15 | 15.73 | 3.70 | 11.88 | 3.74 |
| Rural | 92.45 | 6.69 | 16.33 | 3.87 | 14.52 | 3.94 |
| Affiliation | ||||||
| Hospital-based | 92.38 | 6.64 | 16.68 | 3.65 | 13.78 | 3.68 |
| Not hospital-based | 91.53 | 8.02 | 15.75 | 3.74 | 12.27 | 3.93 |
| Agency Size | ||||||
| Single Agency | 91.49 | 8.23 | 15.72 | 3.96 | 12.22 | 4.13 |
| Multiple branch Agency | 92.15 | 6.06 | 16.41 | 2.60 | 13,35 | 2.81 |
| CMS program participation | ||||||
| Medicare Only | 91.84 | 8.22 | 15.71 | 4.03 | 11.56 | 3.91 |
| Both Medicare and Medicaid | 91.55 | 7.80 | 15.90 | 3.66 | 12.67 | 3.91 |
| Hospice care program | ||||||
| Provide | 91.54 | 7.23 | 16.38 | 3.22 | 13.51 | 3.25 |
| Not Provide | 91.62 | 7.95 | 15.81 | 3.78 | 12.34 | 3.98 |
ED visit, emergency department visit; CMS, Centers for Medicare and Medicaid Services
Table 3 shows the changes in accreditation status over time. Between 2015 and 2019, the overall number of accredited HHAs slightly decreased every year, from 2852 accredited HHAs in 2015 (37%) to 2782 accredited HHAs in 2019 (36.1%). Over this five-year period, 2378 agencies (30.9%) were always accredited, 4461 agencies (58%) were never accredited, and 858 agencies (11.2%) experienced changes in accreditation status (374 agencies gained accreditation, 443 agencies lost accreditation, and 41 agencies experience both gaining and losing accreditation).
Table 3.
Yearly Changes in Home Health Agency Accreditation Status
| Year | Total HHAs (N) | Accredited N (%) | Not Accredited N (%) | Maintained Accreditation N (%) | Gained Accreditation N (%) * | Lost Accreditation N (%) * |
|---|---|---|---|---|---|---|
|
| ||||||
| 2015 | 7697 | 2852 (37.05%) | 4845 (62.95%) | -- | -- | -- |
| 2016 | 7697 | 2837 (36.86%) | 4860 (63.14%) | 2722 (35.36%) | 115 (1.49%) | 130 (1.69%) |
| 2017 | 7697 | 2826 (36.72%) | 4871 (63.28%) | 2714 (35.26%) | 112 (1.46%) | 123 (1.60%) |
| 2018 | 7697 | 2804 (36.43%) | 4893 (63.57%) | 2709 (35.20%) | 95 (1.23%) | 117 (1.52%) |
| 2019 | 7697 | 2782 (36.14%) | 4915 (63.86%) | 2689 (34.94%) | 93 (1.21%) | 115 (1.49%) |
| Total | -- | -- | -- | -- | 415 (5.39%) | 485.30%) |
Compared to previous year.
Figure 1 presents the trends in home health care quality based upon agency accreditation status at baseline year. On average, the timely initiation of care rates in 2015 were 91.2% for accredited agencies and 91.9% for non-accredited agencies respective, which increased to 93.9% and 94.8% in 2019 respectively. Hospitalization rate slightly decreased between 2015 and 2019 for both accredited (0.63% decrease) and not accredited (0.69% decrease) agencies with accredited agencies having a lower rate of hospitalization. In the case of ED visit rate, both accredited and not accredited agencies experienced similarly increase in ED visit rate (accredited: 0.46% increase; not accredited: 0.44% increase) with accredited agencies having a lower ED visit rate.
Figure 1.
Trends in home health-care quality by agency accreditation status at baseline.
We further explored trends in home health care quality over time based upon changes in agency accreditation status over time (agencies categorized into 6 groups: never accredited, lost accreditation, lost and then gained accreditation, gained and then lost accreditation, gained and kept accreditation, and always accredited). These results are presented in Appendix A1-A3. Agencies that never received accreditation during the study period (2015–2019) had the lowest rate (89.3%) of timely imitation of care at baseline year; agencies that gained and kept accreditation had the highest rate (95.8%) of timely initiation in 2019 and they also made the largest improvement (3.5%). Interestingly agencies experienced loss of accreditation and then re-gained it had the lowest hospitalization rate (14.4%) in baseline; agencies that had accreditation all the time had the lowest hospitalization rate (14.7%) in 2019; and agencies that were without accreditation at baseline but gained and kept accreditation had the largest decrease in hospitalization rate (0.8%). This was also the only agency group that had a decrease in ED visit rate while other agency groups were more or less with some increase in ED visit rates between 2015 and 2019.
Estimates of the relationship between home health care quality and agency accreditation status and changes in accreditation status are presented in Table 4. Our estimates show that being accredited was associated with lower rates of hospitalization (Coef: −0.43; P = 0.000) and emergency department visits (Coef: −0.79; P = 0.000). There is no difference in timely initiation of care between accredited and not-accredited agencies (Coef: −0.18; P = 0.258). Compared to agencies lost accreditation over the study period, those that were always accredited, received accreditation, and were always not accredited had a 1.87 (P = 0.000), 1.25 (P = 0.006), and 0.73 (P = 0.061) higher rate of timely initiation of care, respectively. Agencies that were always accredited also had a lower rate of emergency department visits (Coef: −0.77; P = 0.001). Changes in accreditation status was not associated with agency hospitalization rate. Furthermore, being accredited at baseline year (2015) were associated with lower rates of timely initiation of care (Coef: −1.49; P = 0.000), hospitalization rate (Coef: −0.33; P = 0.007), and emergency department visits (Coef: −0.46; P = 0.001).
Table 4.
Relationship Between Home Health Agency Accreditation Status, Changes in Accreditation Status, and Quality of Care
| Timely imitation of care | Hospitalization | ED visits | ||||
|---|---|---|---|---|---|---|
|
|
||||||
| Coef. | P | Coef. | P | Coef. | P | |
|
| ||||||
| Model 1 | ||||||
| Accreditation status (comparison: not accredited) | ||||||
| Accredited | −0.18 | 0.258 | −0.43 | 0.000 | −0.79 | 0.000 |
| Time^ | 0.72 | 0.000 | −0.24 | 0.000 | 0.12 | 0.000 |
| Model 2 | ||||||
| Accreditation status change (comparison: lost accreditation) * | ||||||
| Remain unaccredited | 0.73 | 0.061 | 0.12 | 0.637 | −0.35 | 0.137 |
| Received accreditation | 1.25 | 0.006 | −0.01 | 0.964 | −0.34 | 0.189 |
| Kept accreditation | 1.87 | 0.000 | −0.04 | 0.864 | −0.77 | 0.000 |
| Accreditation status at baseline year/accredited | −1.49 | 0.000 | −0.33 | 0.007 | −0.46 | 0.001 |
| Time^ | 0.68 | 0.000 | −0.35 | 0.000 | 0.08 | 0.000 |
The time variable indicated the calendar year in analysis.
Status changes between 2 years, e.g., changes of accreditation status from 2015 to 2016, 2016 to 2017, etc.
ED visits, emergency department visits.
All models were controlled for agency characteristics and considering clustering of repeated measures within each agency
Discussion
To the best of our knowledge, this is the first study that empirically examined accreditation status of home health agencies and its association with quality of care. Findings from this study provide insights to understand characteristics of home health agencies that are more likely to seek and receive accreditation. More importantly, this study provides empirical evidence to understand whether or not HHAs with accreditation outperform non-accredited HHAs on national quality indicators that are also closely tied to financial reimbursement.
Our finding of the differences in organizational characteristics of home health agencies with and without accreditation suggests that agencies with certain organizational features are more likely to seek and receive accreditation. Agencies with more resources, such as for-profit agencies or agencies in urban areas, are more likely to receive accreditation at the beginning and maintain its accreditation status over time.21 In return, being accredited may better position these agencies to attract clients and thus grow its business. This is not surprising given that seeking accreditation is associated with a fee, which may not be affordable to some agencies, such as agencies that also serve Medicaid beneficiaries or are not-for-profit or government agencies. Furthermore, our findings also imply that accredited and not-accredited agencies may have different views of accreditation and/or employed different management strategies to improve, promote, and advertise their services.
Our findings of the relationship between accreditation status, changes in accreditation status, and quality of care indicators suggest that seeking and receiving accreditation could be one potential approach for improving quality of home health care. This finding is consistent with research of accreditation in other care settings. One example is the Magnet recognition program for hospitals, and researchers have repeatedly reported a positive association between Magnet recognition and quality of care and patient outcomes.22–24 Although limited, available data suggests that the current standards and criteria used in evaluation processes for accreditation mainly focus on organizational structure and care processes. These evaluative metrics are in alignment with desirable efforts outlined in the classic model for quality of care, Donabedian’s Structure-Process-Outcome Model.25,26 This model emphasizes the importance of having established, appropriate care structure and processes for improving quality of care and promoting patient outcomes.
At the same time, it should be noted that despite the identified significant relationship between home health agency accreditation status and quality of care, the absolute differences in quality-of-care measures between agencies with and without accreditation were not always substantial. These findings indicate that while the current standards and criteria are helpful in recognizing excellence of home health care and helping agencies improving care delivery to some extent, there are also opportunities for revising accreditation standards to better align with critical aspects of home health care quality using emerging empirical evidence. Timely revisions and updates in accreditation standards are particularly important given the rapid increases in home health care population, care complexity, care diversity, and dynamic home health policies.14–16 There is a need to conduct an in-depth review of current standards in use by accrediting organization to identify areas for improvement.
Our findings related to agencies that never received accreditation during the study period should be interpreted cautiously. It is not appropriate to simply assume that all these agencies did not provide good quality of care. As previously mentioned, seeking accreditation is associated with a cost. It is therefore possible that some of the agencies that never received accreditation in our study could be those that never sought or applied for accreditation due to financial constraints or other considerations. To better understand home health accreditation, it is desirable to ask for input from home health agencies regarding their decision-making processes and experience of seeking accreditation.
This study generated knowledge about home health agency accreditation; however, it has several limitations that should be noted. First, despite the inclusion of close to 8000 home health agencies in the United States, agencies that did not have complete 5-year data on study quality indicators were not included. According to reporting requirements from CMS, those agencies are more likely to be small agencies. Our findings may not be applicable to those agencies. Second, we only examined three quality indicators due to availability of longitudinal data on quality measures. Though these three indicators measured both care processes and outcomes, future studies should consider other quality indicators (e.g., patient-reported quality outcomes) using different data sources. Third, we used quality indicators from the Home Health Compare program, which provide aggregated data at the agency level. Though some adjustment for differences in patient populations across agencies are considered in calculating the agency-level measure,17 it is possible that some patient characteristics were not included for adjustment. Future research should consider using patient-level data to confirm the relationship between home health agency accreditation and quality of care.
Despite these limitations, findings from this study have several implications. Individuals who are looking for a home health agency for themselves or their loved one may consider accreditation status as one of the quality indicators for decision-making. When affordable, agencies who are committed to providing high quality care but face challenges in identifying specific areas for improvement should consider seeking accreditation. The specific standards and criteria regarding excellence of care from accrediting organizations could be helpful for improvement. For agencies that are more likely to experience financial constraints, such as not-for-profit and/or rural ones as indicated in this study and previous research,27 some federal resources/support for seeking accreditation could be helpful. Lastly, it is necessary for accrediting organizations to revise and update their standards and criteria timely in alignment with national quality indicators.
In conclusion, our study provides some of the very first evidence to characterize features of home health agencies that are more likely to receive accreditation and to demonstrate a positive relationship between home health agency accreditation and quality of care. Our findings suggest that the accreditation process itself can be a potentially effective approach for improving home health care, particularly with timely updated accreditation standards/criteria in great alignment with patient outcomes. To better understand the application and impact of home health agency accreditation, future research is warranted to conduct an in-depth review of current accreditation standards and criteria as well as explore home health agencies’ views, decision-making processes, and experience of seeking accreditation.
Supplementary Material
Acknowledgements
This work was supported by the National Institute on Aging under Grant [R03AG070581, PI: Ma].
Footnotes
Declaration of Interest Statement
The authors report there are no competing interests to declare.
Contributor Information
Chenjuan Ma, NYU Rory Meyers College of Nursing, New York, NY 10010.
Hillary J. Dutton, NYU Rory Meyers College of Nursing, New York, NY 10010.
Bei Wu, NYU Rory Meyers College of Nursing, New York, NY 10010.
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