Context and purpose: The Centers for Medicare and Medicaid Services (CMS) monitor hospital 30-day readmissions to improve healthcare quality and reduce costs. Our organization prioritizes efforts to monitor patients discharged from our hospital to prevent and manage potential complications. Registered nurses (RNs) in care management and primary care (PC) play vital roles in transition care management (TCM) to ensure patient safety across the continuum of care. PC RNs perform discharge follow-up (DCFU) calls to patients with moderate or high risk for readmission scores to ensure that patients and/or caregivers understand the discharge plan of care. Key elements of the DCFU call include medication review, education to support self-management, assisting patients and/or family to access necessary care and services, and facilitating follow-up appointments. When CMS instituted new guidelines for TCM coding in 2017, PC RNs updated DCFU workflows to incorporate requisite TCM elements. We discovered that CM discharge RNs were intermittently contacting mutual patients to assess DCFU needs. To improve patient satisfaction and reduce duplicative efforts, we collaborated with CM RNs to revise DCFU/TCM processes.
Background: In 2020, CM RNs partnered with an external vendor to utilize DCFU robocalls for all hospital discharges. With a focus on improving patient care, PC and CM RNs joined forces to enhance nurse-to-nurse communication and leverage resources. Mutual goals were to streamline our DCFU processes, optimize inpatient to outpatient care transitions, and ensure that patients’ needs were being met.
Implementation strategies: Robocalls began 48 hours post-discharge. Our CM partners agreed to move the initial call to 24 hours post-discharge to meet CMS requirements. Patient responses to robocall questions are recorded. If patients indicate they feel worse than at discharge, have questions regarding discharge instructions or medications, need home health services or medical equipment, and/or would like to speak to the care team, a CM RN calls the patient. We agreed if CM RNs identified PC patients with concerns, a direct call and handoff to a PC RN would occur via our electronic medical record communication platform.
Three PC RNs were designated to perform all DCFU calls for a 6-month pilot period. Training on access and review of robocall information was provided. A smartphrase for ease and standardization of documentation was created. PC nurses reviewed daily DCFU reports and accessed robocall logs. If patients indicated they were doing well and did not need follow-up, TCM documentation was completed. Monthly workgroup meetings were held to discuss workflow issues, review call volumes, and identify opportunities for improvement.
Learning outcomes: Patient engagement with robocall technology was impactful in streamlining DCFU efforts. Patient robocall response rates remained consistent at 88% pre-pilot and 89% post-pilot. Patient concerns requiring callback were relatively unchanged at 28% pre-pilot and 29% post-pilot. Average number of DCFU calls per day by PC RNs decreased from 15 per day pre-pilot to 4 per day post-pilot. TCM smartphrase utilization helped to reduce documentation time. Collaboration and coordination among CM and PC nurses are essential for safe transitions of care.
Purpose: Our aims were to compare the impact of a team of interprofessional providers working with office-based addiction (OBAT) nurses across three community health centers on 1) the presence of nurse sensitive indictors and 2) impact of care on time to stabilization in patients taking buprenorphine. Through the lens of the nursing role effectiveness model, nursing interventions related to care coordination and transition management in patients on medication-assisted treatment were examined.
Background: Interprofessional teams are useful in providing complex care to patients with substance use disorder. Predictors of treatment outcomes such as age, socioeconomic status, and social supports have been studied in addiction treatment. The individual contributions of the OBAT nurse to the team approach are not well understood. Understanding the role of the OBAT nurse in relation to other team members may contribute to the design of team based care delivery models.
Methods: A cross-sectional study of 382 patients in OBAT programs from three community health centers was conducted. Documentation from interprofessional team members was reviewed and collected in REDCap. Linear regression was conducted to identify significant factors in predicting time to stabilization, defined as achieving a third opiate-free toxicology screen. Logistic regression was used to identify significant associations between patient demographics, care team members, and documented interventions. Analyses of aggregate data were conducted, as well as analyses split by community health center for comparison. SPSS version 27 was used to conduct the analyses.
Results: Care coordination and transition management indictors were present in all programs. Overall, patients’ time to stability on buprenorphine was decreased by approximately five months when a recovery coach was on the OBAT nurses’ team (p=0.03) and by seven months when the patient was referred for and received counseling services (p=0.001). Interestingly, the presence of the OBAT nurse in combination with a recovery coach significantly influenced attention to patients’ housing stability and food security. When analyzed by community health center, counseling significantly decreased time to stability in one health center’s patients (p=0.01), while significantly increasing time to stability in another health center’s patients (p=0.02). Counseling had no significant effect on time to stability in the third health center. In one health center, the nurse sensitive indicator, care coordination, operationalized as goal setting significantly reduced time to stability (p=0.04). Goal setting was a significant predictor of time to stability in all health centers. Another predictor of time to stability in two of the health centers was the OBAT nurses’ attention to harm reduction techniques, 96% (p
Problem/background: According to the U.S. Department of Veterans Affairs (VA), 200,000 service members transition from military to civilian life each year. The military-to-civilian transition is recognized as a complex and dynamic process. Despite the efforts of current transition programs, service members continue to experience adjustment challenges and psychosocial stressors. These challenges were aggravated by the onset of the COVID-19 pandemic due to high unemployment rates, a nationwide housing crisis, as well as lack of access to medical care as the medical community’s focus shifted to addressing the acute needs of the pandemic.
Theoretical framework: Three theories provided the framework surrounding the concepts of adaptation, transitions and social identity. Sr. Roy’s adaptation model assumes the human as an adaptative system, where behaviors are the result of coping. Meleis’ theory of transitions views transitions as complex and acknowledges the changes in identities and patterns of behavior. Lastly, Tajfel & Turner’s social identity theory assumes that a person’s self-concept is based on their membership in a group.
Methods/implementation: A cross-sectional, phenomenological project was completed. Volunteers were recruited through a local nonprofit, military transition support referral agency. Convenience sampling resulted in n=10 veterans who recently transitioned (March 2020 and July 2021) from active duty military service to civilian life. An 8-question semi-structured interview with probing questions was conducted via Zoom. Emerging themes developed and a phenomenological analysis was completed through a selective approach.
Results: Despite a small sample size, race and ethnicity diversity are well represented, as 50% identified as other than white. Other demographics captured include rank (80% enlisted, 20% officer), separation type (70% involuntary, 30% voluntary), branch of service (90% Navy, 10% Marine Corps), level of education (40% completed bachelor’s degree or higher, 60% with some college), and gender (60% male, 40% female.) Ages ranged from 23-38 (mean 31.5 years) and years of service ranged from four-14.5 years (mean 9.8. years). Four emerging themes were identified: who am ?, dual identity, social isolation, and civilian life: for better or for worse.
Discussion: Identified limitations in this project include a small sample size as well as participant and student bias. Participants enrolled in the military transition support program may be better prepared than those who did not. Translating the emerging themes into practice include monitoring for other life transitions and providing supportive interventions and referrals. It is also imperative that service members transitioning to civilian life have appropriate care coordination to ensure continuous access to medical and mental health, before, during, and after this complex transition. In understanding the implications of military service throughout life, it is vital that veterans are identified through the American Academy of Nursing’s “have you ever served?” campaign. Furthermore, it should be more broadly acknowledged that the VA and the Department of Defense require the support of community clinicians to ensure veteran-centered and culturally sensitive care is provided across healthcare systems.
At a large tertiary care pediatric facility, hundreds of thousands of ambulatory care patients are seen annually. The majority of these patients spend countless hours a week attending school. As more care is transitioning to ambulatory care settings, it has become apparent that consistent and thorough care coordination between clinic and school settings is needed to meet the complex needs of pediatric patients. An educational program was developed specifically for ambulatory care nurses to increase awareness around the importance of communicating, educating and coordinating care with schools. This educational program development has required the work of a multidisciplinary task force, including care coordinators, school nurses, primary care nurses, and specialty care nurses to address the specific needs of school-aged pediatric patients. The goal of this task force is to streamline communication between ambulatory care facilities and the school nurses who support our patients day to day.
The program was developed after research indicated an abundance of issues families face returning to school after being diagnosed with a chronic illness. Additionally, research was done to address the gaps in knowledge among nurses. School nurses were interviewed to address their concerns when children return to school. This information was combined into a presentation with the goals of educating nurses regarding knowledge of the barriers families and school nurses face when children with a chronic illness attend school, awareness of educational and healthcare plans and the role providers should take when their patients attend school. The presentation has been given to a home care/hospice group, multiple groups of ambulatory care nurses and school nurses. An evaluation was given after the presentation.
Lack of consistency educating schools regarding patients who are returning with a chronic illness creates gaps in care that can lead to poor school attendance, decreased school performance, and undue stress to our patients and families. These gaps are only increasing as we encounter more chronically ill children returning to school. Nurses have the ability to bring change even in a large tertiary facility. Through this process, it has become clear we need to include school nurses as part of our care teams. An important step in this process is continuing to educate ambulatory care nurses on the importance of school health and school attendance. We need to develop guidelines that include consistent and clear lines of communication with school nurses. We can, as nurses, bridge these gaps by advocating for the most comprehensive quality care for our patients.
In a small academic endocrinology practice, a nurse-physician collaboration was started to increase the amount time in range (TiR) for patient’s glucose readings while decreasing the patient’s A1C. This is achieved by patients granting the clinic access to their uploaded continuous glucose monitor (CGM) readings. Traditionally, trends in patients’ glucose readings may only be brought to the provider’s attention during a crisis or an office visit which may be up to 12 months apart. The individual CGM manufactures have web-based tracking systems for their products. Patients are encouraged to sign-up with CGM manufactures’ website (Abbott’s Libreview, Dexcom Clarity, Medtronic Carelink, Tandem T-Connect) with a personal account and allow the tracking system to share that data with the clinic. This sharing of glucose readings is achieved by individual patients accepting the clinic’s invitation to share data. This shared data gives the provider access to glucose readings in between office visits and supports making changes based on real time data. Recommendations to change in plan of care (POC) by the provider will be relayed by nursing via phone, and/or a patient portal message will be sent. Patient data later will be reviewed to support adherence with the diabetes regimen. This is achieved by nursing log into clinic account of CGM websites to spot check patients’ target readings. Nursing uploads CGM reports of the patients that fail to meet the predetermined threshold of 70% CGM target range to the patient’s charts. Nursing notifies provider through the patient portal. Provider reviews the data for trends and make any recommendations, if needed, to the POC and relay that information in writing to nursing. Nursing then will notify patients of changes, if any. Nursing will update patients’ med list if necessary. Nursing reassess the patient’s CGM readings in two weeks or as ordered by provider. Nursing gathers the following information: initial time in range, initial A1C, current time in range, and current A1C.
Since the start of this project in July 2020 to current date April 2021, a period of 9 months, our clinic’s average TiR had increased by 3.4 percentage points, the average A1C has decreased by 2.4. It is hypothesized with more time these results should improve to a point. This is a rolling enrollment so as more diabetic patients choose to use a CGM, the initial average should remain fairly consistent, as the current average may fluctuate with time vs. participants. Anecdotally, patients have voice their satisfaction about the follow up by nursing and medical team to their CSM reports. One of the patients stated they are always grateful for the call from “our favorite nurse.”
Significance and background: The COVID-19 pandemic posed unprecedented global challenges that countries and healthcare institutions were not fully prepared to face with a magnitude of this level. In the wake of this crisis, healthcare organizations had to reorganize their systems and processes at a rapid pace in response to the complexities brought by this pandemic.
Purpose: One of the difficulties hospitals face is balancing the management of COVID-19, while delivering care for other serious medical cases. Although non-emergent treatments and procedures were paused, chronic diseases could not be ignored because delaying or deferring treatments could be detrimental to a patient’s prognosis, like cancer. Despite the threats of this virus, the ambulatory care treatment center (ATC) aimed to prevent disruptions in oncology care with the development of a dedicated treatment space for patients with a suspicion or confirmed diagnosis of COVID-19.
Intervention: The organization focused on three goals: protect our vulnerable patients, ensure the health of our workforce, and minimize community spread. Using these goals as guiding principles, the COVID-19 core leadership team (CCLT) and the ATC leadership created an infusion space, acute care unit (ACU), for symptomatic PUI or COVID-19 + patients that required emergent treatment or testing before completing 20 days of quarantine. This space was converted into two zones: yellow zone for symptomatic PUI and red zone for confirmed positive cases. Infrastructural changes included visual cues to identify these high-risk zones and creating spaces in working areas that adhered to social distancing requirements. Dedicated staff were selected to work in the two areas to prevent cross-contamination and received education and training on managing patients with infections. A workflow process was developed to include a designated screening/check-in area, elevator, entry and exit points, with patients being personally escorted for arrivals and discharges to minimize exposure areas. The ACU also provided physicians and advanced practice providers (APP) a space to perform outpatient procedures as needed for this patient population. Managing and protecting the healthcare team was also crucial because of the increased risk of exposure.
Evaluation: Managing and protecting patients, healthcare teams, and visitors is extremely crucial do to increase risked of exposure with COVID-19 positive patients. The ACU has treated an average of 3-5 patients per day, with no incidents of staff infection while providing care. Additionally, there were no incidents of nosocomial infections to other patients due to having designated routes to ACU specifically for COVID positive patients.
Discussion: COVID-19 continues to overwhelm the healthcare environment. Organizations strive to learn from this experience and strategize effectively to manage and eventually recover from this crisis. These lessons learned will help organizations prepare for any future outbreaks resulting in a pandemic.
Caring for patients with cancer encompasses more than simply treating a diagnosis. Nurses working in outpatient oncology must address the complex psychosocial needs faced by their patient population. Preparing a new graduate nurse to thrive in this environment requires thinking far beyond technical skills. They must be equipped with the tools to deliver holistic patient-centered care.
Due to the misconception that a nurse’s initial role is best suited for the inpatient setting, new graduates are frequently overlooked when ambulatory care staffing needs are considered. However, as the complexity of care delivered in specialty clinics such as oncology expands, so too does the need for new graduates to begin their professional careers in that environment.
At a large academic medical center, an existing nurse residency program added an ambulatory care track to support this growing care delivery area. In August 2021, the first cohort of two ambulatory care nurse residents matched to the institution’s outpatient cancer center. While charting the course for a new graduate is never easy, navigation tools provided by professional nursing organizations and clinical knowledge obtained from expert oncology nurses served as a roadmap for transition to practice.
Utilizing resources from the American Academy of Ambulatory Care Nursing, clinical nurse educators developed a series of lectures exploring foundational concepts that new ambulatory care nurses must master. These key aspects included ambulatory care nursing as a specialty, patient teaching, care coordination, telephone triage, and patient-centered care. Simulation experiences, quizzes, and games were integrated to promote retention. Interactive discussions on psychosocial aspects of ambulatory care nursing encouraged residents to reflect on their concerns about transition shock and explore personal strategies for successful transition to practice.
To provide a framework for the resident’s clinical experiences, clinical nurse educators and departmental leaders developed a learning pathway and rotation schedule. Paired with seasoned oncology nurse preceptors, residents rotated through multiple medical oncology subspecialty clinics. For a more comprehensive understanding of diagnostic and treatment options, they rotated through the radiation oncology, infusion, and magnetic resonance imaging areas. Finally, the residents shadowed on the inpatient oncology floor to better understand transitions of care.
Due to the multidimensional concepts inherent in cancer care, a PhD-prepared nurse practicing in outpatient oncology delivered a series of lectures analyzing these unique challenges. Presentation topics from this lecture series included scientific basis of cancer, clinical trials, oncologic emergencies, and psychosocial factors of oncology care.
With the success of the inaugural cohort, the ambulatory care nurse residency track's next available start date will expand from one launch clinic to four or more participating clinical specialties. Based on the amount of currently accepted job positions, the number of residents in the second cohort is projected to double.
While traditional onboarding experiences are important to all new graduate nurses, understanding holistic care holds special importance for developing the outpatient oncology nurse. Addressing the intricate psychosocial needs of this patient population throughout the ambulatory care nurse resident’s onboarding better prepared them to reach independence in provision of care to the patient with cancer.
The purpose of this project was to examine the impact of preoperative patient education on length of stay and readmission rates. Rates of readmission after colorectal surgery exceed hospital readmission rates for any other surgical procedure with total cost of patient care exceeding $37,000 per colorectal patient and is significantly higher when complications occur. Colorectal surgery complications have been found to increase healthcare costs upwards of 196%.
The American Society of Colon and Rectal Surgeons (ASCRS) Clinical Practice Guidelines Committee determined standard length of stay after colorectal surgery to be 5-8 days and readmission rates to be as high as 35.4%. Almost 8% of 12,732 patients were readmitted and being able to favorably change the rate of readmissions could potentially save $3.6 million for every 1000 colorectal readmissions.
A literature review was performed using keywords (colorectal surgery, readmissions, colorectal complications, colorectal surgery education, preoperative education). A setting was selected for implementation and written approval from required bodies for use of these was obtained. Approval from the university IRB was obtained, and participants were selected from a large colorectal clinic. Informed consent was obtained from the participants, the project was implemented. Collected data was statistically analyzed and reported via a written platform.
A pre-operative teaching session, 1-3 hours in duration, was conducted within 30 days of the operation. It was provided live for available participants and virtually for those unable to attend. The education was provided by the principal investigator who has more than seven years’ experience in providing care to colorectal patients. Education was administered verbally using PowerPoint presentation. Participants were provided a hard copy of the presentation before the program to promote note taking. For those unable to attend, the hard copy was sent via mail with delivery confirmation and/or email.
Of the 55 participants, 34 were control participants and 21 were experimental. There was a statistically and clinically significant decrease in readmission rates. Of the 21 experimental participants, zero were readmitted after discharge, and 9 of the 34 control participants were readmitted. There was a decrease in the overall total length of stay from 3.76 to 3.43 days.
Evidence-based project findings from research support an individualized approach to patient care in helping to reducing healthcare costs. Narrowed focus on patient education assists patients to better care for themselves, in turn, also decreasing morbidity and mortality. Consumers and providers would benefit from the decrease in costs, morbidity, and mortality. The financial benefit from cost savings would allow healthcare systems to approach their nursing workforce and face those fighting for fair workloads from a positive business advantage.
The setting for this evidence-based practice project is an ambulatory care clinic at a tertiary care center in the Middle-East North Africa (MENA) region. Home healthcare options in the country are limited, and providing care at home for children with tracheostomies was not an expectation for families. Historically, families would bring their children to the clinic to tend to all tracheostomy concerns, performing few cares or troubleshooting few issues at home. This added an increased pressure to an already over-booked ENT ambulatory care clinic. Especially during COVID, where all patients needed to received COVID swabs and await results before able to attended appointment times.
Our multidisciplinary team comprises an otolaryngologist – head and neck surgeon, a clinical nurse, a tracheostomy nurse practitioner, respiratory therapist, dietician, and a speech and language practitioner. Our team provides inpatient care and outpatient follow-up for new and chronic tracheostomy patients. Multidisciplinary tracheostomy care team, standardized tracheostomy protocol and policies, family empowerment are the keys in improving quality care for these patients.
Purpose: The purpose of this project is to
• Improve the competence of families in providing home tracheostomy care, including daily cares, troubleshooting and emergency response.
• Decrease the number of outpatient clinic visits for children with tracheostomies.
• Improve quality of life for patients and families.
Description: The ENT team developed an education program, taking into account the religious norms and cultural considerations of the patients and families in the region. Parents/caregivers were initially assessed for their level of understanding and their individual capabilities. Parent/caregiver teaching included daily tracheostomy care and suction, tracheostomy insertion, use of silver nitrate to address granulation tissue, and responding to emergency situations including tube blockage and emergency tracheostomy change. Parents had to achieve an average of 3 successful demonstrations independently to be signed off as competent. The length of training was average of 2-4 weeks pre- and post-surgery, as it was tailored to meet individual training needs of parents/caregiver.
Evaluation/outcome: 54 out of 61 of our patients are now trained. Instead of coming every 4-6 weeks in clinic, patients are now coming only once every 3-6 months for routine follow-up. Only 5 of our patients are still coming to our clinic for routine monthly change. Very good feedback was received from families about their ability to effectively provide tracheostomy care management at home, and parents felt empowered in managing tracheostomies independently. Average monthly visit for tracheostomy clinic decreased 71.3%, from 61 down to average 17.5 monthly visits, which saves and average of 32.6 hours clinic time per month. Only 1 out of 61 patients had a complication after discharge, with parents unable to reccanulate at home. The patient reported to emergency with no serious complication.
This project demonstrates the feasibility of parental involvement in home tracheostomy care in this region.
It is historically difficult to manage, engage and increase self-support for complex care patients challenged by 1) multiple co-morbidities, exacerbated by SDOH; 2) rural environments, lacking infrastructure to accommodate and fill in gaps across the continuum of care; 3) provider shortages, notably behavioral health supports for psycho-social complexity; 4) low incomes; and 5) low health literacy. This patient/caregiver population often come from disadvantaged backgrounds and equate to high-need, high-cost patients that frequently utilize expensive acute care services, often in place of primary care, delaying an enhanced and/or optimized patient outcome. To address the needs of these complex care patients, health systems, communities, and value-based payment models have attempted and implemented patient-centered medical homes and integrated behavioral health and care navigation/coordination, including community health worker-led efforts to better stabilize patients and reduce fragmentation of supportive services. While these models have seen some success, they are rarely informed by patients who encounter actual lived barriers in rural America.
Unfortunately, due to the same barriers that often inhibit optimal care access, high-need, high-cost patients with complex medical and/or psychosocial needs have been particularly difficult to engage in patient-centered outcomes research (PCOR) and/or comparative effectiveness research (CER) on rural and frontier population care model effectiveness, providing little available evidence that incorporates the priorities and perceptions of patients and their caregivers.
To advance a thin evidence base, increasing patient, provider, policymaker, and payor knowledge about this vulnerable population, Logan Health, formerly Kalispell Regional Medical Center (KRMC) and the Flathead County community, located in northwest Montana, embarked on a research support project building preliminary capacity to conduct PCOR by engaging high-need, high-cost patients and their caregivers (B), providers/clinicians (A), and community health workers (C) in qualitative research methods to better understand attitudes and key barriers to patient-centered CER in a rural setting, gaining understanding of engagement priorities and learning how to best engage the population in the advancement of rural/frontier care model effectiveness.
In September 2019, Logan Health was awarded a Eugene Washington PCORI Engagement Award to “Build Capacity to Break Down Barriers to Complex Care Navigation in Rural America,” resulting in a 5-year roadmap, poster board, and fact sheet. The project was recently completed October 31, 2021.