Updated: 03/22/21
Updated: 03/22/21
Methods: Parameters for inclusion: CCM is offered to patients with two or more chronic conditions expected to last twelve months or until the death of the patient. All patients in the CCM program will complete the ICAN tool at initial enrollment and then at all subsequent visits with the RN care coordinator.
Results/evaluation: A retrospective review of patient self-assessed burdens will be done at enrollment and then at each subsequent visit over a period of one year. Data will be analyzed by number and type of burdens, chronic conditions, age, and gender as well as trends over time while patients are enrolled in CCM.
Implications for practice/learning outcome: Connecting with patients; establishing trusting relationships; meeting them where they are at; and understanding patients’ needs, barriers, and values is advantageous to improving patient self-management and health care outcomes.3
References
1. Leppin, A.L, Montori, V.M & Gionfriddo, M.R. (2015). Minimally disruptive medicine: a pragmatically comprehensive model for delivering care to patients with multiple chronic conditions. Healthcare, 3(1), 50 -63.
2. Boehmer, K.R., Hargraves, I.G., Allen, S.V. et al. Meaningful conversations in living with and treating chronic conditions: development of the ICAN discussion aid. BMC Health Serv Res 16, 514 (2016). https://doi.org/10.1186/s12913-016-1742-6
3. Vanderboom, C.E., Thackery, N. L., & Rhudy, L. M., (2015). Key factors in patient-centered care. Nurse care coordinators’ perspectives. Applied Nursing Research, 28(1), 18-24. https://doi.org/10.1016/j.apnr.2014.03.004
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/26/21
Background of the problem: Transitions can greatly impact hospital readmission risk when there is a gap in communication. An absence of a standard process to facilitate communication between the skilled nursing facility (SNF) and patient care team leads to gaps in information related to patient’s plan of care, medication management and continuity of care.
Literature review: Communication tools, care coordination, and collaboration between SNFs and patient care team support patient continuity of care and reduces patient risk for 30-day readmission. Care coordination of patient transitions reduces readmissions. Health information technology tools facilitate communication and reduce patient risk.
Objective/purpose: Establishing a standardized process of communication between SNF and primary care providers fosters partnerships and reduces fragmentation of patient care with SNF transitions. Utilizing a health information technology (HIT) web- based tool, CarePort, facilitates communication of patient information and supports care coordination of patient care that occurs with SNF transitions.
Methods: Established partnerships and implemented standardized process of communication with SNFs to support communication of SNF patient transition information. Standardized communication of SNF patient transitions using templates and technology tools. Standardized communication tools, with use of templates, to support patient SNF transition care between the SNF setting and primary care practice team members, population health medical assistant (PHMAs), HIT team, and primary care coordinators. Implemented standardized process of communication with SNF and primary care team, with the use of CarePort portal, for monitoring SNF patient transitions and outcomes. Establish and increase collaborative partnerships with SNF care team to support communication of transition patient information, using standardized documentation, technology, and CarePort portal. Utilize technology to collect, store, monitor, track, and communicate patient information and data related to patient SNF transition status. Utilize CarePort technology portal tool to support communication of SNF patient transitions.
Outcomes: Improvement of communication between SNF and primary care team members in 6-month time period. Increase # of SNF telephone contacts from primary care team. Increase # of SNF partnerships formed through CarePort portal. Reduced 30-day hospital readmissions of SNF discharged patients with implementation of standardized communication tools. Standardization of communication tools and collaborative partnerships supports communication of SNF patient transition information and bridges transitions from SNF setting and primary care. Communication tools and collaborative relationships facilitate and support care coordination of patient transition care with SNF and primary care settings.
Conclusion/implications for nursing practice: Developing standard processes of communication between SNF and primary care team members supports patient transition care and decreases readmissions. Establishing collaborative relationships and utilizing technology supports continuity of patient care across the continuum. Standardized communication tools support communication of patient information between SNF and primary care practices and foster team collaboration.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Background: The emergence of the novel coronavirus disease (COVID-19) continues to stretch the capacity of health care systems worldwide. High hospitalization rates for infected patients have put immense strain on health care workers who tirelessly exert themselves to deliver quality inpatient care amidst critical resources shortages. Exploring their experiences may identify ways in which ambulatory health care can be incorporated into infection control and prevention responses and ease the pressure on hospital resources during future pandemics.
Methods: Purposive, convenience, and snowball sampling were used to recruit 60 registered nurses who provided inpatient care during the COVID-19 outbreak in Hubei. Semi-structured interviews were conducted. Participants were asked to share their work experiences during the pandemic, including challenges faced in patient care, related coping strategies, and suggested improvements for future pandemic responses. Interviews were audio recorded and transcribed verbatim. Resulting data was coded and analyzed thematically according to Braun and Clarke’s (2006) framework.
Results: Participants reported multiple challenges in their experiences of delivering patient care during the COVID-19 outbreak. Due to high caseloads, nurses worked lengthier shifts and took on additional responsibilities in order to make up for shortages in hospital staff, leading to an increase in psychological and physical distress. Support came in the form of fever clinics which reduced nurses’ burden by screening patients for COVID-19 in the community and freeing up valuable hospital resources. Suggestions to improve future epidemic responses and prevent the overburdening of hospital staff included the installation of additional fever clinics and the delivery of reliable public health education in primary care settings, which may raise awareness on infection prevention and control measures and potentially lower overall infection rates.
Conclusions: Nurses in hospital settings have been overstretched due to an unprecedented surge in patients requiring hospitalization. Psychological and physical stress were frequently reported, with a potential reduction in the quality of inpatient care. To protect and reduce strain on hospital staff, ambulatory health care may be explored as a solution to increase community capacity in responding to future infectious disease outbreaks, thus allowing hospital resources to be directed towards the most serious patients and further optimizing pandemic control efforts.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Description: Results from the EMA trial helped to secure funding for a 12-month pilot to restyle two full-time medical assistants as EMAs. Goals were to reduce message volume downstream by capturing certain message types, increase efficiency and order by routing messages strategically, and have care team members work to their highest scope of practice. Each EMA was assigned to 11 providers. Two new in-baskets were created: one to address patient advice requests and one for prescription refills. In the 2-month training period, EMAs completed direct portal messages and provider requests to call results. A suite of smart phrases was created to provide language and tone consistency when communicating with patients. In addition, EMAs responded to incoming patient calls and assisted with prescription refills. Team member assignments were adjusted on high-volume message days. Data on in-basket total message volumes and number of refill messages for EMAs and providers was collected at pre-pilot, training, and post-implementation intervals.
Evaluation/outcome: Total in-basket message volumes increased for physicians and EMAs from pre-pilot levels to training and post-implementation intervals. However, the number of in-basket messages by user type indicated that physician patient advice messages decreased from 98% pre-pilot to 64% during implementation. Physician refill messages decreased from 100% pre-pilot to 69% during implementation. EMAs managed 28% of patient advice messages during training and maintained at 27% during implementation. EMA refill messages increased from 19% during training to 36% during implementation. EMAs had a sense of ownership, developed competence, and focused on message completion. The smaller feedback loop showed an increase in efficiencies while providing shorter message response times, which increased patient satisfaction. Smart phrases were well received by patients and the practice. The greatest impact to the practice will come from task shifting among remaining nursing and allied health staff. With the EMA managing patient messages, other team members can focus on clinical tasks nearer to the limit of their licensure such as pre-visit planning, wellness services, or procedures. This task shifting has potential for a greater impact to providers than patient message volume reduction alone.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Description: While rapid response teams (RRT) have been identified as best practice in hospital settings, there is a paucity in the literature regarding emergency medical response in ambulatory care patients, particularly in an outlying, stand-alone clinics with limited staff support (Rojas et al., 2017).
The quick response team (QRT) at this clinic is responsible for reporting to all QR calls within a 300,000 square foot building which encompasses approximately 50,000 square feet of medical space. This clinic is the largest outlying independent ambulatory care clinic within the local network with approximately 22,000 enrolled patients. The QRT consisted of two registered nurses (RN) and was responding in a “ramp up” model. This “ramp up” methodology is described as being nurse-led and does not include a provider responding simultaneously. In contrast, a “ramp down” approach consists of a provider concomitantly responding to all QR calls.
Growing frustration motivated a team of clinic nurses to evaluate nursing staff’s perception of the QRT process and perceived barriers. A layout analysis was completed and demonstrated multiple decision points resulting in time wasted in locating a provider. A similar circumstance was also found in the literature, where it was noted that “awaiting the physician arrival from the ICU further delayed necessary transitions to the ED” (Dechert et al., 2013). We found this “ramp up” phenomenon was also present in our outlying clinic setting where nurses were responding alone. Implementation of a “ramp down” approach in our clinic included executing a “doc of the day” plan where a provider is assigned to respond (with the RNs) to all QR calls for the day. Doc of the day was implemented in October 2019.
Evaluation and outcome: “Time spent” data was collected for all quick response calls 180 days prior (99 calls) and 180 post-implementations (54 calls) of doc of the day. The average time spent on QR calls was 48 minutes prior to “doc of the day” in comparison to 30 minutes post-implementation. Nursing staff surveys were also completed 180 days prior and 150 days post-implementation. In May 2019, 75% of surveyed primary care nurses reported frustration in finding a provider, and 57% of nurses indicated they would hesitate in initiating an intervention without a provider present. These values decreased by 58% and 27%, respectively.
Implementing a “ramp down” approach in responding to emergency situations in an ambulatory care clinic decreased the mean duration of QR calls by 18 minutes over a six-month period. The learning outcome and conclusion is that simultaneous provider response expedites the dispositioning of patients requiring evacuation to a higher level of care, decreasing the potential for poor patient outcomes. This “ramp down” approach and process improvement scenario may be implemented in other similar outpatient settings to improve efficiency, patient safety, and staff satisfaction.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Methods: The American Association of Diabetes Educators (AADE) offers an online, self-paced diabetes paraprofessional program that provides an advanced body of core knowledge and skills related to diabetes education and management that is geared towards health care professionals. This program was utilized as a basis for the DHPP in this organization. Clinical staff (MAs and LPNs) were nominated by managers to enroll in the program. Care was taken to ensure that nominations were spread across many of the ambulatory care offices to ensure a standardized approach to diabetic education for patients and families across the organization. The DHPP is run by a registered nurse (RN) clinical educator who oversees the students, providing additional mentoring and tutoring as needed as the students learn the material. Once the students complete the program, their successes are celebrated and they immediately begin their work. They choose a taskforce (2019 taskforces include eye exam; foot care; importance of hemoglobin A1C (HA1C); importance of micro-albumin testing; and monitoring blood pressure, nutrition and blood sugars) and work together to develop educational materials and forums for their co-workers, patients, and family members. Materials may include huddle talking points, flyers and bulletin boards for the offices, pamphlets, and short videos for staff and/or patients, etc. The RN clinical educator remains a mentor and works with a dyad physician champion partner; together they provide guidance and final approval on all teaching points, materials, and forums.
Results/outcomes: The major metric for this program is the organizational diabetes bundle compliance score. YTD the score is above target at 78.22 (up from 2018 close of 77.33). Additionally, this program is designed to positively impact employee engagement and patient experience.
Implications for practice: The developed curriculum incorporates chart prep, patient communications, rooming practices, and office staff communications to provide standardized education across ambulatory care setting. This DHPP drives quality outcomes, fosters a positive environment that promotes engagement and professional development among staff, and empowers patients living with diabetes the knowledge required to achieve optimal health outcomes. The cost of the program is about $200 and is covered by many organizations’ continuing education benefit. On average, the program takes two about months to complete with a majority of the work being completed by the students at home.
Reference
1. CDC.gov. (2019). Division of diabetes translation at a glance. Retrieved from https://www.cdc.gov/chronicdisease/resources/publications/aag/diabetes.htm
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Aim: STOP the use of the dorsogluteal site for intramuscular injections by the ambulatory nurses. The nurses reported they were using the unapproved dorsogluteal intramuscular site (Lippincott, 2019). The nurses' rationale for the site selection was due to patient requests and the nurses’ discomfort using the ventrogluteal and vastus lateralis injection sites. The literature reported similar findings. Of reporting nurses, 35.9% were uncomfortable using the ventrogluteal site (Sari, Sahin, Yasar, Taskiran, & Telli, 2017). The targeted group for the change of practice were nurses who administered testosterone and ceftriaxone injections. Testosterone was given by over 190 nurses in 15 nurse-run clinics. Ceftriaxone was given by over 220 nurses in the 22 back offices for primary care, urgent care, and specialty care.
Methods: The quality improvement project used the knowledge-to-action framework (Graham et al., 2006), which focused on leadership support of the goal, use of audits, feedback, and content expertise. The audits were released monthly to the managers with the names of those staff who did not select the correct injection site. The managers used the audits to provide feedback to the individual nurse to guide change of practice. Those nurses who reported they were uncomfortable with their current skills were supported with training and practice sessions for ventrogluteal and vastus lateralis injections.
Results: The results were a successful change of practice and sustainability. The testosterone group interventions began in March 2019. This group demonstrated a reduction of incorrect site selection from the baseline of 10.6% to less than 1% from December 2019 through December 2020. The ceftriaxone group interventions began in May 2019. This group demonstrated a reduction of incorrect site selection from the baseline of 20% to less than 1% from December 2019 through December 2020.
Conclusions: The results demonstrated sustainability of the desired practice change for the correct site selection for intramuscular injections by the ambulatory nurses. Patient safety was improved with the reduction of the selection of the dorsogluteal site. The knowledge-to-action framework can be used with other identified clinical practice gaps where implementation and adherence are critical to success.
References
- Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13-24. doi:10.1002/chp.47
- Lippincott Procedures. (2019, June 14). Intramuscular injection, ambulatory care. Retrieved from https://procedures.lww.com/lnp...,injection,site,injections,sites,injecting&a=false&ad=false
- Sari, D., Şahin, M., Yaşar, E., Taşkiran, N., & Telli, S. (2017). Investigation of Turkish nurses’ frequency and knowledge of administration of intramuscular injections to the ventrogluteal site: Results from questionnaires. Nurse Education Today, 56, 47-51. doi:10.1016/j.nedt.2017.06.005
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
The nurses at adult primary care, a primary care clinic serving the underinsured, uninsured, and most vulnerable population of Hartford, CT, and surrounding areas, in line with the CDC Healthy People 2020 National Immunization Goals 2 saw the need to increase vaccinations in the ambulatory care setting for patients who were identified with a COPD diagnosis. Approximately 200 patients were identified and placed into four categories: patients with no history of pneumococcal vaccinations, patients who have received/not received PPSV23, patients who have not received PCV13, and patients who have received both PPSV23 and PCV13.
This nurse-driven initiative involved members of the whole team, including medical assistants who called eligible patients that were identified to come to the office for vaccinations during established pneumonia vaccination clinics. Nurses also proactively reviewed provider schedules for patients aged 65 and older who needed PCV13 vaccination. A best practice advisory (BPA) was established in the electronic medical records (EMR) with the support from the Hartford HealthCare (HHC) system support office to alert providers of the patients’ need for the pneumococcal vaccine. Vaccination rates for the population in this pilot increased as a result of this initiative: pneumovax 23 vaccination increased to 89% and prevnar 13 vaccination increased to 77%. In conclusion, the BPA has increased providers awareness to patients’ need for vaccinations in general. Once the BPA proved effective, HHC began using the BPA system wide to increase vaccinations rates. We have also seen an increase in vaccinations rates for TDap, hepatitis A, hepatitis B and influenza.
References
1. Pennant, K, Costa,J, Fuhlbrigge,A, Sax, P, Szent-Gyorgyi, L, Coblyn, J Desai,S. Improving Influenza and Pneumococcal Vaccination Rates in Ambulatory Specialty Practices. Open Forum Infectious Diseases 2015;1-9.
2. CDC. Healthy People 2020 National Immunization Goals.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
Objective: The objective was to develop and implement a temporary solution to continue point-of-care testing and encourage patients who were able to adopt remote testing. The team’s top priorities were patient safety and comfort and nurse well-being and confidence, ultimately decreasing fear by providing care that is safe and efficient. ASD anticoagulation leaders needed a solution that would allow the team to continue point-of-care testing, maintain staff safety, and encourage fearful patients to continue international normalized ratio (INR) testing.
Methods: To ensure continuity of care for patients whose care required face-to-face visits, the team stood up seven centralized drive through tent locations and expanded home-testing capabilities. To deliver care in this new model the team took the following steps:
1. Encouraged patients who could enroll in home testing to do so and collaborated with a home-testing company to increase efficiency of enrolling new home-testing patients.
2. Utilized RNs not engaged in care at testing sites to enhance the anticoagulation services virtual team.
3. Established tent testing locations:
• Leadership assigned staff to dedicated tent teams for the duration of the project.
• RNs at tent sites donned proper PPE in accordance with Centers for Disease Control guidelines and our organization’s policy while working at tent sites.
• Tent site teams instructed patients to stay in their vehicles and wear a mask through the entirety of the visit.
• Patients were arrived in the electronic medical record (EMR) for their visits.
• While the patient remained in their vehicle the tent site RNs conducted a COVID-19 screening and completed an anticoagulation assessment.
• Virtually the team completed the visit in the EMR and managed the patient’s dosing.
Results: Warfarin management was successful; enrolled patients’ average time in therapeutic range (TTR) remain unchanged from pre COVID-19 averages. Prior to clinics closing in March 2020, the average TTR was 60.75%. In April and May 2020, the average TTR was 61%. In addition to maintaining TTR performance, the new workflows decreased appointment length of time from 20 minutes to less than 5 minutes. Shorter appointments reduced risk of exposure for patients and the nurses. Home testing also expanded; over 100 patients were transitioned to home testing. Lastly, the new process maintained staff safety; there were no reported cases of RNs exposed or diagnosed with COVD-19.
Conclusion: Our nurses skillfully collaborated to ensure safe, effective, and efficient care. Anticoagulation services temporarily closed 32 clinics for 8 weeks, quickly implementing innovative solutions to continue care for patients who could not receive care virtually. Patients continued to have their POC testing and warfarin therapy monitored, resulting in very little variation in TTR.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
Updated: 03/22/21
Updated: 03/22/21
The rapid spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which causes coronavirus disease 2019 (COVID-19), has impacted health care systems across the United States. Emergency departments (ED), intensive care units, hospital wards, and outpatient clinics have seen an unrelenting increase in patient care volumes due COVID-19. Many other factors of this new virus compound the impact of increased volumes including viral spread, safety, personal protective equipment (PPE), and the unknown. This led to a burgeoning need to transform the way we delivered care to patients who were either presenting to the ED with COVID symptoms, identified by serology testing as being COVID (+) and/or calling the health care system.
Under the guidance of the Centers for Disease Control and Prevention guidelines and internal infections disease physicians and nurses, a system-wide response was developed to manage COVID (+) patients safely, effectively, and efficiently while containing the spread of the virus to health care workers. A resource team was gathered, working collaboratively to respond to the need to ultimately provide safe care for our COVID (+) population. The team included an operational support staff, physician, clinical nurse, advance practice leader, and the ambulatory care educator and utilized the A3 methodology for improvement. The group focused on managing patients via outpatient methods to minimize unnecessary contact with health care workers and the general population as well as decrease ED visits.
Two separate care delivery models were created, one virtual and one for in-person encounters. Within the delivery model, key components included staff needed and skill set, training/education, technology requirements, patient access to the care system, care delivery process, personal protective equipment (PPE), and safety. Re-purposing physical space and workflow onsite to minimize COVID transmission was paramount, as well as requiring the virtual team to have a designated workspace with the requisite technology. A dedicated team of redeployed clinical staff worked were precepted in person and/or virtually. Infectious disease training and donning and doffing of PPE was provided by the ambulatory care educator and the infectious disease physician in person and also via on-line and virtual formats.
Analysis of the care delivery system included reconciling data from the scheduling platform and the organization’s data warehouse management reports to determine the number of calls, messages, patients, and number of encounters. A daily dashboard was provided that displayed the total numbers of patients that received care in person or virtually.
From March 27, 2020, and April 3, 2020, through June 15, 2020, the nascent virtual outpatient management clinic (VOMC) and the newly created onsite outpatient acute respiratory clinic (ARC) managed 6,215 calls/encounters and 604 outpatient visits, respectively.
Through multidisciplinary leadership, clinical innovation, and use of the best available evidence, the team created best practices for the transformation of the care delivery and management of primary care patients who were battling COVID-19. The approaches described can provide best practices for leaders in response to newly identified infectious disease and the care delivery models.
Learning Objective:
- After completing this learning activity, the participant will be able to assess innovations being used by other professionals in the specialty and evaluate the potential of implementing the improvements into practice.
