Purpose: Management of chronic disease is changing the focus and delivery of healthcare. Approximately 70% of deaths annually and costs for chronic disease now consume 86% of U.S. healthcare dollars. There is a need to shift the focus of healthcare from episodic care to behavioral approaches to increase wellness and prevent disease. Registered nurses (RNs) are well positioned to lead these changes through care coordination and transition management (CCTM). Research shows patient engagement is key to managing chronic conditions and improving health outcomes. However, gaps were identified in CCTM to include lack of standardization, ability to measure patient engagement, and the ability to quantify the RN role.
Methods: A valid and reliable patient engagement tool was adapted from a VA behavioral modification program. An electronic medical record (EMR) template was created to measure patient engagement in CCTM. A pilot group of RNs was created and a cohort of 22 high-risk patients were identified. The pilot group utilized the patient engagement template and shared best practice. Utilization of the patient engagement template allows nursing to listen to the voice of the veteran, incorporate whole health practices, and elicit positive health outcomes.
Results: The data collected indicated a cost avoidance related to readmissions of $75, 633.16, and aggregate improvement of 95% related to probability of event (death or readmission). The qualitative data reported positive patient outcomes that include weight loss, alcohol cessation, decrease in hospital admissions, and improvement in diabetes and overall health. The patient engagement template has expanded to the Gainesville VAMC, the southeastern region of the VA, and two national platforms and was found to be widely accepted.
Conclusion: As a result of this multifaceted approach, the patient engagement template has been disseminated among all primary care nurses in the South Georgia, Florida, Puerto Rico, and the Virgin Islands and the patient engagement EMR template has been incorporated into the EMR CCTM note template for use by all the primary care nurses at these locations. The patient engagement template is now the standard for CCTM in primary care. As the patient engagement template is utilized, we are now collecting data to isolate how nursing can further impact a patient’s stages of change, motivating factors for change, barriers to make changes, and action plans for disease-specific needs.