Caroline Stephens, PhD, GNP, FAAN

Title(s)Associate Professor, Community Health Systems
SchoolSchool of Nursing
AddressLocation Required, #001
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    Collapse Biography 
    Collapse Education and Training
    University of California, San FranciscoPh.D.2010Gerontological Nursing & Health Policy
    University of PennsylvaniaPost-Master's Certificate, Gerontological Nurse Practitioner2001School of Nursing
    University of PennsylvaniaMSN, Geropsychiatric Advanced Practice Nursing (CNS)2000School of Nursing
    University of PennsylvaniaBSN1999School of Nursing
    University of California, DavisBS, Biological Psychology with Minor in Human Development & Aging1995College of Letters & Sciences
    Collapse Awards and Honors
    UCSF2013  - 2018Clinical Translational Sciences Institute (CTSI) KL2 Scholar
    San Francisco VA Medical Center2010  - 2012National Veteran's Administration Quality Scholar (VAQS)
    UCSF2010  - 2012John A. Hartford Foundation/Atlantic Philanthropies Claire M. Fagin Fellow
    Alpha Eta Chapter - UCSF2010Sigma Theta Tau International Nursing Honors Society Research Award
    UCSF20089th Annual UCSF Outstanding Health Policy Paper Award
    UCSF2007  - 2009John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Scholar
    UCSF2006  - 2007Cota Robles Fellow
    University of Pennsylvania 2002University of Pennsylvania Dean's Award
    University of Pennsylvania 1999University of Pennsylvania Nightingale Award
    Xi & Alpha Eta Chapters1999Sigma Theta Tau, International Nursing Honors Society

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

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

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

    Collapse Research 
    Collapse Research Activities and Funding
    Improving Palliative Care Access through Technology (ImPAcTT): A Multi-Component Pilot Study
    NIH K76AG054862Aug 15, 2017 - Jun 30, 2022
    Role: Principal Investigator
    State of the Future in Global Aging, Dementia & Mental Health: Bridging Leadership, Science, Practice and Policy
    NIH R13AG056140Jul 1, 2017 - Jun 30, 2019
    Role: Principal Investigator

    Collapse Bibliographic 
    Collapse Publications
    Publications listed below are automatically derived from MEDLINE/PubMed and other sources, which might result in incorrect or missing publications. Researchers can login to make corrections and additions, or contact us for help. to make corrections and additions.
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    Altmetrics Details PMC Citations indicate the number of times the publication was cited by articles in PubMed Central, and the Altmetric score represents citations in news articles and social media. (Note that publications are often cited in additional ways that are not shown here.) Fields are based on how the National Library of Medicine (NLM) classifies the publication's journal and might not represent the specific topic of the publication. Translation tags are based on the publication type and the MeSH terms NLM assigns to the publication. Some publications (especially newer ones and publications not in PubMed) might not yet be assigned Field or Translation tags.) Click a Field or Translation tag to filter the publications.
    1. Interrater reliability of chart-based assessment of functional impairment after pediatric injury using the functional status scale. J Trauma Acute Care Surg. 2023 09 01; 95(3):391-396. Melhado CG, Kao E, Hogan-Schlientz J, Crane D, Shui AM, Stephens CQ, Evans L, Burd RS, Jensen AR. PMID: 37012628.
      View in: PubMed   Mentions:    Fields:    Translation:Humans
    2. High-Quality Nursing Home and Palliative Care-One and the Same. J Am Med Dir Assoc. 2022 02; 23(2):247-252. Ersek M, Unroe KT, Carpenter JG, Cagle JG, Stephens CE, Stevenson DG. PMID: 34953767; PMCID: PMC8821139.
      View in: PubMed   Mentions: 3     Fields:    Translation:Humans
    3. Postimplementation Evaluation of a Machine Learning-Based Deterioration Risk Alert to Enhance Sepsis Outcome Improvements. Nurs Adm Q. 2020 Oct/Dec; 44(4):336-346. Linnen DT, Hu X, Stephens CE. PMID: 32881805.
      View in: PubMed   Mentions:    Fields:    Translation:Humans
    4. Advances in geropsychiatric nursing: A decade in review. Arch Psychiatr Nurs. 2020 10; 34(5):281-287. Stephens CE, Massimo L, Harris M, Evans LK, Buckwalter KC. PMID: 33032747; PMCID: PMC7547149.
      View in: PubMed   Mentions: 1     Fields:    Translation:Humans
    5. 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 Jul 1; 60(1):289-290. Oh OA, Patel PK, Max MW, Stephens SC, Ritchie RC, Smith SA. .
      View in: Publisher Site   Mentions:
    6. Transitioning to Life in a Nursing Home: The Potential Role of Palliative Care. J Palliat Care. 2021 Jan; 36(1):61-65. Halifax E, Bui NM, Hunt LJ, Stephens CE. PMID: 32106767; PMCID: PMC8127871.
      View in: PubMed   Mentions: 1     Fields:    Translation:Humans
    7. "They Don't Trust Us": The Influence of Perceptions of Inadequate Nursing Home Care on Emergency Department Transfers and the Potential Role for Telehealth. Clin Nurs Res. 2020 03; 29(3):157-168. Stephens CE, Halifax E, David D, Bui N, Lee SJ, Shim J, Ritchie CS. PMID: 31007055; PMCID: PMC10242499.
      View in: PubMed   Mentions: 10     Fields:    Translation:Humans
    8. USING THE CONSOLIDATED FRAMEWORK FOR IMPLEMENTATION RESEARCH (CFIR) TO GUIDE THE IMPLEMENTATION OF IMPACTT. Innovation in Aging. 2018 Nov 1; 2(suppl_1):776-776. David DD, Wertz WV, Barrientos BP, Allison AT, Flint FL, Lee LS, Ritchie RC, Stephens SC. .
      View in: Publisher Site   Mentions:
    9. LESSONS LEARNED IMPROVING PALLIATIVE CARE ACCESS THROUGH TECHNOLOGY (IMPACTT) IN NURSING HOMES. Innovation in Aging. 2018 Nov 1; 2(suppl_1):775-776. Stephens SC, David DD, Hunt HL. .
      View in: Publisher Site   Mentions:
    10. IMPROVING PALLIATIVE CARE ACCESS THROUGH TECHNOLOGY (IMPACTT): PRELIMINARY FINDINGS FROM A PILOT STUDY. Innovation in Aging. 2018 Nov 1; 2(suppl_1):776-776. Stephens SC, David DD, Wertz WV, Allison AT, Flint FL, Barrientos BP, Lee LS, Ritchie RC. .
      View in: Publisher Site   Mentions:
    11. UNDERSTANDING NURSING HOME STAFF ATTITUDES TOWARDS DEATH AND DYING. Innovation in Aging. 2018 Nov 1; 2(suppl_1):776-777. Bui BN, Halifax HE, Uy UE, Hunt HL, David DD, Lee LS, Ritchie RC, Stephens SC. .
      View in: Publisher Site   Mentions:
    12. ASSESSING TECHNICAL FEASIBILITY AND ACCEPTABILITY OF PROVIDING TELEHEALTH PALLIATIVE CARE IN NURSING HOMES. Innovation in Aging. 2018 Nov 1; 2(suppl_1):777-777. Wertz WV, Bui BN, Uy UE, Barrientos BP, David DD, Lee LS, Ritchie RC, Stephens SC. .
      View in: Publisher Site   Mentions:
    13. PAIN AND EMERGENCY DEPARTMENT USE IN THE LAST MONTH OF LIFE BY OLDER ADULTS WITH DEMENTIA. Innovation in Aging. 2018 Nov 1; 2(suppl_1):635-635. Hunt HL, Ritchie RC, Patel PK, Stephens SC, Cataldo CJ, Smith SA. .
      View in: Publisher Site   Mentions:
    14. Pain and Emergency Department Use in the Last Month of Life Among Older Adults With Dementia. J Pain Symptom Manage. 2018 12; 56(6):871-877.e7. Hunt LJ, Ritchie CS, Cataldo JK, Patel K, Stephens CE, Smith AK. PMID: 30223013; PMCID: PMC6289599.
      View in: PubMed   Mentions: 6     Fields:    Translation:Humans
    15. Nurse practitioner and physician assistant oncology workforce for older adults. Journal of Clinical Oncology. 2018 May 20; 36(15_suppl):e18514-e18514. Coombs CL, Stephens SC, Kolevska KT, Max MW. .
      View in: Publisher Site   Mentions:
    16. Challenges in Aging, Dementia, and Mental Health: New Knowledge and Energy to Inform Solutions. J Am Geriatr Soc. 2018 04; 66 Suppl 1:S1-S3. Stephens CE, Evans LK, Bradway C, Buckwalter K. PMID: 29659007; PMCID: PMC6526043.
      View in: PubMed   Mentions: 3     Fields:    Translation:Humans
    17. Emergency Department Use by Community-Dwelling Individuals With Dementia in the United States: An Integrative Review. J Gerontol Nurs. 2018 Mar 01; 44(3):23-30. Hunt LJ, Coombs LA, Stephens CE. PMID: 29355877; PMCID: PMC5982587.
      View in: PubMed   Mentions: 12     Fields:    Translation:Humans
    18. Palliative Care Eligibility, Symptom Burden, and Quality-of-Life Ratings in Nursing Home Residents. JAMA Intern Med. 2018 01 01; 178(1):141-142. Stephens CE, Hunt LJ, Bui N, Halifax E, Ritchie CS, Lee SJ. PMID: 29159368; PMCID: PMC5833507.
      View in: PubMed   Mentions: 14     Fields:    Translation:Humans
    19. The Current State of U.S. Geropsychiatric Graduate Nursing Education: Results of the National Geropsychiatric Graduate Nursing Education Survey. J Am Psychiatr Nurses Assoc. 2015 Nov-Dec; 21(6):385-94. Stephens CE, Harris M, Buron B. PMID: 26597905; PMCID: PMC7486864.
      View in: PubMed   Mentions: 4     Fields:    Translation:Humans
    20. Pain in Community-Dwelling Older Adults with Dementia: Results from the National Health and Aging Trends Study. J Am Geriatr Soc. 2015 Aug; 63(8):1503-11. Hunt LJ, Covinsky KE, Yaffe K, Stephens CE, Miao Y, Boscardin WJ, Smith AK. PMID: 26200445; PMCID: PMC4778418.
      View in: PubMed   Mentions: 29     Fields:    Translation:Humans
    21. 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.
    22. 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.
    23. The effects of cognitive impairment on nursing home residents' emergency department visits and hospitalizations. Alzheimers Dement. 2014 Nov; 10(6):835-43. Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. PMID: 25028060; PMCID: PMC6528828.
      View in: PubMed   Mentions: 14     Fields:    Translation:Humans
    24. In C.S. Landefeld, A. Chang, & B. Williams (Eds.), Current Geriatrics Diagnosis & Treatment. 2014. Stephens, C. Confusion in the Elderly: Common Clinical Questions.
    25. Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr. 2014 Mar 20; 14:35. Stephens CE, Sackett N, Govindarajan P, Lee SJ. PMID: 24650076; PMCID: PMC3994482.
      View in: PubMed   Mentions: 4     Fields:    Translation:Humans
    26. 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.
    27. Emergency department use by nursing home residents: effect of severity of cognitive impairment. Gerontologist. 2012 Jun; 52(3):383-93. Stephens CE, Newcomer R, Blegen M, Miller B, Harrington C. PMID: 22056961.
      View in: PubMed   Mentions: 16     Fields:    Translation:Humans
    28. 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. View Publication.
    29. 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. View Publication.
    30. Care coordination for cognitively impaired older adults and their caregivers. Home Health Care Serv Q. 2007; 26(4):57-78. Naylor MD, Hirschman KB, Bowles KH, Bixby MB, Konick-McMahan J, Stephens C. PMID: 18032200; PMCID: PMC2504359.
      View in: PubMed   Mentions: 26     Fields:    Translation:Humans
    31. Cognitively impaired older adults: from hospital to home. Am J Nurs. 2005 Feb; 105(2):52-61; quiz 61-2. Naylor MD, Stephens C, Bowles KH, Bixby MB. PMID: 15674058.
      View in: PubMed   Mentions: 34     Fields:    Translation:Humans
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