Caroline Stephens, PhD, GNP, FAAN
Associate Professor
Community Health Systems
School of Nursing

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

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

From a teaching perspective, I am passionate about, and locally and nationally involved in, figuring out innovative ways to infuse more gerontological and geropsychiatric content into the generalist APN curriculum and across disciplines.

• Evaluating Health Literacy in Families of Injured Children: A Prospective Observational Cohort Study at a Level One Pediatric Trauma Center.
  Journal of pediatric surgery 2024 Melhado C, Kao E, Evans L, Stephens CQ, Lee H, Jensen AR
• Mortality risk following end-of-life caregiving: A population-based analysis of hospice users and their families.
  Social Science & Medicine 2024 Mike Hollingshaus, Ken R. Smith, Huong Meeks, Katherine Ornstein, Eli Iacob, Djin Tay, Caroline Stephens, Rebecca L. Utz
• Dying with dementia in nursing homes: A population-based study of decedents and their families.
  Journal of the American Geriatrics Society 2024 Stephens CE, Utz R, Tay D, Iacob E, Hollingshaus M, Goodwin R, Farrell TW, Bouldin E, Edelman L, Reinke LF, Smith K, Ellington L, Ornstein K
• Factors associated with trauma recidivism in young children.
  The journal of trauma and acute care surgery 2024 Stephens CQ, Melhado CG, Shui AM, Yap A, Moses W, Jensen AR, Newton C
• DYING WITH DEMENTIA IN NURSING HOMES: A POPULATION-BASED PERSPECTIVE OF DECEDENTS AND THEIR FAMILIES.
  Innovation in Aging 2023 Caroline Stephens, Rebecca Goodwin, Eli Iacob, Michael Hollingshaus, Ken Smith, Djin Tay, Rebecca Utz, Katherine Ornstein
• WHO DIES IN A RURAL NURSING HOME WITH AND WITHOUT FAMILY? EVIDENCE FROM THE UTAH POPULATION DATABASE.
  Innovation in Aging 2023 Rebecca Goodwin, Katherine Ornstein, Eli Iacob, Michael Hollingshaus, Ken Smith, Djin Tay, Rebecca Utz, Caroline Stephens
• Family Ties at End-of-Life: Characteristics of Nursing Home Decedents With and Without Family.
  Palliative Medicine Reports 2023 Caroline E. Stephens, Djin Tay, Eli Iacob, Michael Hollinghaus, Rebecca Goodwin, Brenna Kelly, Ken Smith, Lee Ellington, Rebecca Utz, Katherine Ornstein
• Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale.
  The journal of trauma and acute care surgery 2023 Melhado CG, Kao E, Hogan-Schlientz J, Crane D, Shui AM, Stephens CQ, Evans L, Burd RS, Jensen AR
• DEVELOPING A RESOURCE FOR LEVERAGING POPULATION DATA SETS TO ADVANCE CAREGIVING SCIENCE.
  Innovation in Aging 2022 Rebecca Goodwin, Katherine Ornstein, Catherine Elmore, Rebecca Utz, Djin Tay, Lee Ellington, Ken Smith, Caroline Stephens
• FAMILIAL AND SOCIODEMOGRAPHIC DETERMINANTS OF PLACE OF DEATH: A RETROSPECTIVE STUDY OF THE UTAH POPULATION DATABASE.
  Innovation in Aging 2022 Brenna Kelly, Heidi Hanson, Huong Meeks, Michael Hollingshaus, Djin Tay, Lee Ellington, Caroline Stephens, Katherine Ornstein
• HEALTH AND WELL-BEING OF FAMILY CAREGIVERS FOLLOWING HOSPICE USE.
  Innovation in Aging 2022 Rebecca Utz, Michael Hollingshaus, Katherine Ornstein, Djin Tay, Caroline Stephens, Ken Smith
• UTILIZING POPULATION DATA TO CHARACTERIZE NURSING HOME DECEDENTS AND THEIR FAMILIES AT THE END OF LIFE.
  Innovation in Aging 2022 Caroline Stephens, Michael Hollingshaus, Brenna Kelly, Djin Tay, Katherine Ornstein, Ken Smith, Rebecca Utz
• High-Quality Nursing Home and Palliative Care-One and the Same.
  Journal of the American Medical Directors Association 2021 Ersek M, Unroe KT, Carpenter JG, Cagle JG, Stephens CE, Stevenson DG
• Postimplementation Evaluation of a Machine Learning-Based Deterioration Risk Alert to Enhance Sepsis Outcome Improvements.
  Nursing administration quarterly 2020 Linnen DT, Hu X, Stephens CE
• Advances in geropsychiatric nursing: A decade in review.
  Archives of psychiatric nursing 2020 Stephens CE, Massimo L, Harris M, Evans LK, Buckwalter KC
• Patterns of Home Health and Hospice Service Use in the Last Year of Life among Community-Dwelling Older Adults with and without Dementia (GP774).
  Journal of Pain and Symptom Management 2020 Anna Oh, Kanan Patel, Wendy Max, Caroline Stephens, Christine Ritchie, Alexander Smith
• Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care.
  Journal of palliative care 2020 Halifax E, Bui NM, Hunt LJ, Stephens CE
• "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth.
  Clinical nursing research 2019 Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS
• ASSESSING TECHNICAL FEASIBILITY AND ACCEPTABILITY OF PROVIDING TELEHEALTH PALLIATIVE CARE IN NURSING HOMES.
  Innovation in Aging 2018 V Wertz, N Bui, E Uy, P Barrientos, D David, S J Lee, C Ritchie, C Stephens
• IMPROVING PALLIATIVE CARE ACCESS THROUGH TECHNOLOGY (IMPACTT): PRELIMINARY FINDINGS FROM A PILOT STUDY.
  Innovation in Aging 2018 C Stephens, D David, V Wertz, T Allison, L A Flint, P Barrientos, S J Lee, C Ritchie
• LESSONS LEARNED IMPROVING PALLIATIVE CARE ACCESS THROUGH TECHNOLOGY (IMPACTT) IN NURSING HOMES.
  Innovation in Aging 2018 C Stephens, D David, L Hunt
• PAIN AND EMERGENCY DEPARTMENT USE IN THE LAST MONTH OF LIFE BY OLDER ADULTS WITH DEMENTIA.
  Innovation in Aging 2018 L Hunt, C Ritchie, K Patel, C Stephens, J Cataldo, A Smith
• UNDERSTANDING NURSING HOME STAFF ATTITUDES TOWARDS DEATH AND DYING.
  Innovation in Aging 2018 N Bui, E Halifax, E Uy, L Hunt, D David, S J Lee, C Ritchie, C Stephens
• USING THE CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH (CFIR) TO GUIDE THE IMPLEMENTATION OF IMPACTT.
  Innovation in Aging 2018 D David, V Wertz, P Barrientos, T Allison, L A Flint, S J Lee, C Ritchie, C Stephens
• Pain and Emergency Department Use in the Last Month of Life Among Older Adults With Dementia.
  Journal of pain and symptom management 2018 Hunt LJ, Ritchie CS, Cataldo JK, Patel K, Stephens CE, Smith AK
• Nurse practitioner and physician assistant oncology workforce for older adults.
  Journal of Clinical Oncology 2018 Lorinda Adaire Coombs, Caroline Stephens, Tatjana Kolevska, Wendy Max
• Challenges in Aging, Dementia, and Mental Health: New Knowledge and Energy to Inform Solutions.
  Journal of the American Geriatrics Society 2018 Stephens CE, Evans LK, Bradway C, Buckwalter K
• Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review.
  Journal of gerontological nursing 2018 Hunt LJ, Coombs LA, Stephens CE
• Palliative Care Eligibility, Symptom Burden, and Quality-of-Life Ratings in Nursing Home Residents.
  JAMA internal medicine 2018 Stephens CE, Hunt LJ, Bui N, Halifax E, Ritchie CS, Lee SJ
• The Current State of U.S. Geropsychiatric Graduate Nursing Education: Results of the National Geropsychiatric Graduate Nursing Education Survey.
  Journal of the American Psychiatric Nurses Association 2015 Stephens CE, Harris M, Buron B
• Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study.
  Journal of the American Geriatrics Society 2015 Hunt LJ, Covinsky KE, Yaffe K, Stephens CE, Miao Y, Boscardin WJ, Smith AK
• Advance Care Planning: A Community-Based Initiative in San Francisco
  SFMS Journal: San Francisco Medicine 2015 Newman, J., Sudore, R., Stephens, C., Miller, BJ, Ritchie, C.
• Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study
  J Amer Geriatr Soc, in press. 2015 Hunt, L.J., Covinsky, K.E., Yaffe, K., Stephens, C., Miao, Y., Boscardin, J., Smith, A.K.
• The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations.
  Alzheimer's & dementia : the journal of the Alzheimer's Association 2014 Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C
• In C.S. Landefeld, A. Chang, & B. Williams (Eds.), Current Geriatrics Diagnosis & Treatment
  2014 Stephens, C. Confusion in the Elderly: Common Clinical Questions
• Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study.
  BMC geriatrics 2014 Stephens CE, Sackett N, Govindarajan P, Lee SJ
• Long Term Services and Supports Policy Issues. In D.J. Mason, J.K. Leavitt, M.W. Chaffee (Eds.), Policy & Politics in Nursing and Healthcare (7th ed.). Elsevier. In press
  Long Term Services and Supports Policy Issues. In D.J. Mason, J.K. Leavitt, M.W. Chaffee (Eds.), Policy & Politics in Nursing and Healthcare (7th ed.). Elsevier. In press 2014 Harrington, C., Stephens, C., Wagner, L.M.
• Emergency department use by nursing home residents: effect of severity of cognitive impairment.
  The Gerontologist 2011 Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C
• Evolving Case Studies as a Learning Resource - Evaluating Acute Confusion: A CNS Perspective. In "Transitioning to the New Model for Regulation of APRNs: Ensuring the APRN Workforce is Prepared to Care for Older Adults"
  Evolving Case Studies as a Learning Resource - Evaluating Acute Confusion: A CNS Perspective. In "Transitioning to the New Model for Regulation of APRNs: Ensuring the APRN Workforce is Prepared to Care for Older Adults". 2011 Stephens, C.
• Impact of California's Medi-cal Long Term Care Reimbursement Act on Access, Quality & Costs. Report Prepared for the California HealthCare Foundation. San Francisco, CA: University of California
  Impact of California's Medi-cal Long Term Care Reimbursement Act on Access, Quality & Costs. Report Prepared for the California HealthCare Foundation. San Francisco, CA: University of California. 2008 Harrington, C., O'Meara, J., Collier, E., Kang, T., Stephens, C., Chang, J.
• Care coordination for cognitively impaired older adults and their caregivers.
  Home health care services quarterly 2007 Naylor MD, Hirschman KB, Bowles KH, Bixby MB, Konick-McMahan J, Stephens C
• Cognitively impaired older adults: from hospital to home.
  The American journal of nursing 2005 Naylor MD, Stephens C, Bowles KH, Bixby MB