AAACN 45th Annual Conference 2020

P11 - Promoting a Healthy Work Environment to Decrease Work-Related Stress

Katherine Frigo, DNP, APRN, NP-C, CNL

Updated: 07/20/20

Purpose: The field of transplant nursing is a vastly changing specialty with many challenges. Transplant nurses often experience stress related to caring for patients through complex medical treatments. Cumulative exposure to work-related stress can lead to provider burnout and an unhealthy work environment. National organizations, such as the American Nurses Association are promoting healthy work environments. With the increased awareness of the negative effects of stress, it is important to implement strategies to promote a healthy workplace. The purpose of this initiative was to determine the impact of mechanical chair massage among registered nurses (RNs) and advanced practice providers (APPs) on perceived stress, blood pressure (BP), and heart rate (HR).

Description: This nurse-led pre-post design practice initiative was conducted in an ambulatory care transplant clinic. A storage closet was repurposed, cleaned, and painted in order to create a warm, calming environment. The massage chair was located in a secured room accessible by key, and the room contained a refrigerator with refreshments and snacks. A total of 24 nurses (RNs and APPs) in the transplant clinic were eligible to participate. Prior to the study initiation, an email was sent to the nurses with screenshots describing the purpose of the initiative, the usage of the chair, and the requirements for completion of the pre-post measures (perceived stress, BP, HR). The massage chair was available for 15-minute cycles and could be pre-scheduled using an Outlook calendar or spontaneously in response to a stressful event.

Evaluation/outcome: Participants self-recorded BP and HR using an Omron wrist-automated cuff device and perceived level of stress using the visual analog scale (0-10). Descriptive statistics were used to assess nurse characteristics and paired t-tests were used to compare differences in BP, HR, and perceived level of stress.

Data were collected from February 1 to October 31, 2019. Among the 110 massage chair encounters, nurses were aged 37.6 ± 7.0 and working in transplant 7.9 ± 8.3 years. There were significant decreases in systolic BP (117.3 ± 10.8 vs 111.7 ± 13.4 mmHg) and diastolic BP 70.8 ±9.8 vs 66.7 ± 10.3 mmHg), respectively p

P12 - Improving Access to Care: APP Optimization in Ambulatory Care Neurosurgery

Shana Osman, MSHA, BSN, RN, CNML

Updated: 07/15/20

Purpose: Healthy People 2020 recognize access to quality healthcare services reduces impact of disease and provides an avenue for health equity. University of Alabama at Birmingham (UAB) is the tertiary care provider for the state and surrounding areas. The high-volume and complex needs of patients referred to the practice resulted in reduced access to care.

Description: The goal was to improve access to comprehensive neurosurgical care at UAB Medicine by implementing advanced practice provider (APP) clinics. Implementation included the development of a business plan for RN-clinical care coordinators and surgery schedulers.

Evaluation/outcome: Increasing APP utilization allowed the department to meet the goal of improving access to care. We were we able to overcome barriers to implementation by working closely with physicians to develop the best APP model for the practice. We anticipate further growth for our APP schedules as the clinic transformation process continues.

References
1. Healthy People 2020 [Internet]. Washington, DC: US Department of Health and Human Services, Office of Disease Prevention and Health Promotion, https://www.healthypeople.gov/...

P13 - Transforming Baccalaureate Curriculum and Ambulatory Care Nurses’ Competencies in Rural and Underserved Settings for Primary Care

Brenda Luther, PhD, RN, Associate Professor, University of Utah College of Nursing

Updated: 07/20/20

Need: Urgent need to transform baccalaureate nursing education to meet healthcare needs highlighted in part from the Affordable Care Act (Macy, 2016; RWF, 2015). Rural and underserved populations disproportionately experience negative health outcomes due in part to limited access to primary care providers. Student preparation needs to focus on complex chronic illness management, transitional care, care coordination, preventative care, population health, advanced care planning, wellness visits, and end-of-life planning.

Undertaking: Integrate primary care content via online modules in current BSN student curriculum as well as develop online primary care content CEs and interactive webinars for community nurses in FQHCs and other ambulatory care.

Challenges: Developing content that highlights nurses' primary care roles into acute care-focused curriculum. Providing professional development to busy working primary care nurses. Increasing primary care competencies of existing nursing faculty.

Initial program successes: Digital badge content cross-walked within undergraduate program curriculum, faculty content experts developed curriculum modules, first badges into curriculum Fall 2019, statewide webinars with ambulatory care nurses in FQHCs with topics of transitional care, chronic illness management, billing and coding, continuing education modules available to RNs in Spring 2020, and increase clinical experiences in rural and underserved FQHCs for BS students.

Nurse Education, Practice, Quality and Retention Program (NEPQR) grant: The goal of the Utah NEPQR is to develop academic-practice partnerships with urban and rural PC clinics in medically underserved Utah settings to provide pathways for student nurses and RNs to receive expanded training in PC nursing.

This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under UK1HP31735, Nursing Education, Practice, Quality, and Retention – Registered Nurses in Primary Care Program.

P14 - Increasing Access to Tobacco Treatment Specialist (TTS) in the Pulmonary Outpatient Setting

Stephanie Storch, BSN, RN

Updated: 07/19/20

Smoking cessation for patients with pulmonary issues is of the utmost importance to improving their health. A tobacco treatment specialist (TTS) is currently employed for several outpatient clinics, offering counseling and support to patients contemplating smoking cessation. Several limitations existed for an efficient and comprehensive referral process. The existing referral process for getting patients in touch with the TTS was provider-driven. Referrals were only placed for patients who discussed their smoking status and readiness to quit with their provider. Provider awareness of TTS services was lacking, and the referral itself was not intuitive to find within the electronic health record (EHR). For these reasons, many eligible patients did not receive referrals to the TTS.

The purpose of this project was to increase access to the TTS for pulmonary clinic patients by utilizing a nurse-driven protocol to refer all active smokers for smoking cessation counseling and initiating a nurse outreach workflow to discuss readiness to quit with patients.

The nurse-driven protocol was created to allow nurses to identify any eligible patients seen within the pulmonary clinic and place a referral to the TTS for smoking cessation counseling. The protocol defined eligible patients as those whom have been seen within the clinic in the last calendar year with an active smoking status. The new workflow for nurse outreach enabled nurses to assess readiness to quit and provide patients with education on services offered by the TTS. All patients referred to the TTS by the nurse-driven protocol and contacted as part of the nurse outreach workflow were tracked to determine whether an appointment had been scheduled with the TTS. Retrospective chart audits were also completed to determine how many eligible patients received referrals to the TTS and ultimately scheduled their appointment prior to the nurse-driven protocol and nurse outreach beginning.

With the implementation of the nurse-driven protocol and nurse outreach workflow, the percentage of active smokers seen within the pulmonary clinic whom received referrals to the TTS increased by 18.2%. The number of visits with the TTS increased by 36%. Patients who were contacted via nurse outreach were 35% more likely to schedule an appointment or consultation with the TTS.

Increasing access to the TTS utilizing the nurse-driven protocol and promoting nurse outreach to discuss readiness to quit allows clinic nurses to practice at the top of their scope. Future implications for this project include expanding nurse outreach to patients who have established care with the TTS to promote adherence to smoking cessation counseling, and ultimately increase the number of patients who successfully quit smoking.

P15 - Best Practice in Cross-System Care Coordination Conferences

Tamara Solem, MN, RN, CCM

Updated: 08/05/20

Practice experts strongly recommend an interdisciplinary approach to care coordination to meet the complex needs of older adults with chronic physical and mental health comorbidities who are also poor. These adults are likely to participate in Medicaid- funded long-term services and supports in the community or in care facilities. The majority are dually eligible for Medicare. Their healthcare costs are among our nation’s highest. Older Medicaid beneficiaries with complex needs are more likely to experience iatrogenic events within health and long-term care settings and to experience earlier mortality when compared to those who are not poor or who have fewer complex needs. Care coordinators often seek to better understand the needs of these complex individuals and to effectively collaborate within and across systems. Although interprofessional collaboration is recognized as best practice, there is currently insufficient evidence to fully support cross-system team building interventions in non-acute healthcare settings. The prevailing biomedical model with its embedded hierarchies often disincentivizes true cross-system collaboration and fails to adequately address the intersections between the individual’s own goals of care, treatment adherence, and socioeconomic risk factors. Despite prevailing understanding that a team of nurses, social workers, community partners, and others are necessary to support both individuals and primary care providers throughout the care coordination process, it can be difficult to ensure that all voices are heard and have a platform to contribute to information-sharing and decision making. Interdisciplinary cross-system care coordination conferences represent an innovative partnership under the umbrella of Oregon’s coordinated care organization service delivery model that allows multiple participants to jointly develop a person-driven plan of care. Specifically, a state-mandated memorandum of understanding stipulates that health plan partners participate with local Medicaid long-term services and supports staff to co-facilitate interdisciplinary cross system care coordination conferences for mutually identified complex individuals and to include those individuals whenever possible. Since their inception in 2015, these conferences have been shown to significantly decrease emergency department visits, inpatient admissions, and associated costs. Care conferences that include both health and social needs planning can also promote person-driven care, create more targeted care plans, increase the quality of care and increase work satisfaction. These collaborative sessions highlight the expertise of all team members, clarify team member roles, and distribute leadership among all the participants. This session, presented jointly by the long-term care innovator agent responsible for initiating and pioneering ICCCs in Multnomah County, Oregon, and an RN health plan partner will describe the process with an emphasis on lessons learned and evidence-based practice specific to collaborative team building across systems. Learning outcomes will focus specifically on establishment of joint metrics, identifying individuals to bring to care conferences, facilitating an interdisciplinary group discussion with a person-driven focus, creating a shared care coordination plan, maintaining confidentiality, and tracking outcomes. There will also be an opportunity for interactive learning and for participants to consider how this model compares to what is available or what could be developed within their own systems.

P16 - The Electronic Multidisciplinary Team Note: Using the CCTM Logic Model to Improve Team Communication in a Cleft and Craniofacial Program

Caitlin Church, BS | Stacy Nance, BSN, RN, CCTM

Updated: 07/20/20

Background/purpose: Cleft and craniofacial teams are required to deliver a multidisciplinary treatment plan to each patient to comply with ACPA parameters of care. Additionally, the Centers for Medicare & Medicaid Services (CMS) have established EHR incentive programs to encourage hospitals to demonstrate meaningful use of certified electronic health record technology (CEHRT), including using CEHRT to communicate directly with patients. Finally, patients and their families expect and need to have access to the patient’s multidisciplinary treatment plan, preferably using electronic consumer tools. Our objective is to demonstrate how one center undertook a QI initiative using the CCTM logic model to deliver a multidisciplinary team note by using one tool to satisfy all three of these communication directives.

Methods/description: To increase staff and patient awareness of the patient portal, a contest was implemented amongst all registration team members to incentivize them to register patients to the portal from March through June 2018. 256 patients were offered portal access by registration staff. 78 (30%) of patients offered successfully signed up and gained portal access. During this time, clinic coordinators provided education to all staff on CCTM logic model and benefits of portal use through QI monthly meetings and email communication. By June 2018, team members were trained on how to offer patients an online patient portal account, access the team note via the EMR, and add their individualized plan. Clinic coordinators launched a pilot of six patient team notes per clinic using the EMR and communicated this to the team. Patients not already signed up for portal access are encouraged to do so by clinic staff nurses through verbal education and pamphlet during a clinic visit. After the patient has seen all designated providers, the team plan is completed and signed by each provider. Once signed, the team coordinator launches a communication to the family via the EMR’s patient portal for their review, which includes a copy of the finalized team note. 62 electronic team notes have been added to individual EMRs as of Sept 17, 2018. Of these 62 patients, 51 (80%) have registered for EMR patient portal access. Since implementation, the team notes overall portal use has increased by cleft and craniofacial patients to over 30% from less than 10%. Families have reported that the portal allows access to the cleft and craniofacial team plan and offers additional path of communication with the team for non-urgent concerns. All cleft team members are able to easily access and add their plan of care with limited disruption to workflow. Limitations of the portal are the exclusion of patients who are non-English speaking, lack access to technology, and wards of the state.

Learning outcome: Describe benefits of using CCTM logic model when implementing EMR patient portal to communicate with families and provide team note; describe how CCTM logic model can assist the multidisciplinary team to deliver high-quality, high- value communication to patients; and evaluate the impact of EMR communication on increased transparency and efficiency.

P17 - Examining Opioid Misuse within a Military Ambulatory Care Setting

Akeeka Davis, MBA, BSN, BSHCS, RN, Nurse Educator, United States Navy

Updated: 07/27/20

Purpose: The objective of this study was to identify military and civilian beneficiaries at risk for opioid misuse. The number of active service members and civilians were identified utilizing the military health system population health portal, which is a clinical decision reporting tool that contains the morphine equivalent daily dose and opioid-induced respiratory depression scoring. The clinical decision support tool is a 2-stage logistic regression machine learning model used to assist clinicians in identifying a patient’s cumulative intake of any drugs in the opioid class over 24 hours.

Background/significance: Prescription opioids continue to be the leading cause of poisoning death in the United States and represent more deaths than heroin and cocaine combined. In the United States, over 64,000 drug overdose deaths were estimated in 2016, with over 20,000 of those deaths related explicitly to fentanyl.1 In 2013, 78.5 billion dollars was spent on opioid treatment, and overdose in the United States and the rates are steadily increasing.2 Less than one percent of active duty service members are addicted to opioids, and the overdose death rate among active duty service members is 2.7 out of 100,000.3

The military health system (MHS) provides complex care to a diverse populace that includes military dependents and retirees, so the problem is multifactorial and does not correlate to just active-duty personnel. It is pertinent that we examine every aspect of this complex problem. Most patients that are on long-term opioid therapy are 45 years of age and older and are representative of the dependent and retiree population.3 The goal of this project provided comprehensive education to providers, nurses, and non-licensed clinical staff. Additionally, during the time of the study, services were expanded to provide non-pharmacological alternatives to patients in efforts to prevent and manage patients who present with specific risk factors that are related to opioid misuse.

This project utilized military health system population health portal (MHSPHP) to identify patients that are at risk for opioid misuse; opioids have become a leading cause of unintentional injury death, even more than motor vehicle accidents or firearm fatalities, according to 2016 state data. Nationwide, the Centers for Disease Control and Prevention reports that overdose deaths related to prescription opioids have quadrupled since 1999.4 Nurses can play an essential role in reducing these deaths, as well as addiction problems, through their assessments and monitoring of patients.

Materials and methods: A total of 27 out of 100 patients met criteria for the study from January 2018 to October 2018. Of the 27 patients identified there were no Naloxone co-prescriptions ordered, only 4 out of 27 patients had case management referrals placed, and there was no education taught to the providers.
Results: Of the 27 patients selected for the study, case management referrals increased by 85%, Naloxone prescriptions increased by 66%, and current primary care manage visits increased by 13%.

Conclusion: Nurses are trained on the importance of opioid misuse, and they are well-positioned to play a leading role in assessing, diagnosing, and managing patients battling addiction.

P18 - RN Role in Rural Diabetic Patients

Sheela Martel, RN | Cheri Williams, BSN, RN-BC

Updated: 07/19/20

Updated: 07/20/20

The nursing team has identified the opportunity to focus on poorly managed diabetic patients in a small, rural primary care practice with two full-time providers. The RNs are responsible for the assessment and education of diabetic patients. This project will help the RNs focus on assessing barriers, socio-economic factors, medication compliance, health literacy, and personal comprehension of managing diabetes to change teaching from a reactive to proactive method of teaching.

The intent of the nursing team is to implement a patient-centered diabetic teaching plan to empower our patient toward improved self-management of their diabetes. Through this proactive and sustainable teaching structure, the RN team will partner with this cohort of diabetic patients in changing teaching methods through increased health- coaching and communication within the nurse-patient relationship.

A literature search using multiple databases was conducted to find evidence-based articles on diabetic patients in rural areas. It was determined that understanding the barriers of rural diabetic patients would lead to best practice for improvement of patient's HgA1C. The prevalence of poor health literacy, socio-economic factors, access to care, and medication compliance are unique inequities within this population.

By assessing barriers of diabetic patients with a HgA1C of 9 or greater, the team has identified the opportunity to influence improvement in the management of diabetes through changes in our nursing clinical practice. A retrospective analysis of prospectively collected data was performed from January 2019 through April 2019. The team considered this to be high-risk diabetic patients. This analysis revealed 22 patients as having a HgA1C of 9 or greater.

The RN team designed a patient-centered, health literacy-appropriate, and culturally sensitive education plan for each patient, which included 1:1 diabetic teaching using the teach-back method and routine follow-up to improve self-management. Through this change in clinic practice and proactive approach to self-management, 20% of the high-risk patients will decrease their HgA1C to below 9 within 9 months.

Data analysis will be done at three-month intervals (September 30, 2019; December 31, 2019; March 31, 2020). September 2019 data has shown a significant improvement in this cohort of diabetic patients, with 68% of patients decreasing their HgA1C and 49% having met the goal of a HgA1C below 9. This project has improved nursing practice with diabetic patients and will continue through March 31, 2020.

P19 - Development of a Primary Care Enrichment Program for Bachelor of Science Nursing Students

Dianna Inman, DNP, APRN | Sharon Lock, PhD, APRN, FNAP, FAANP

Updated: 07/15/20

Registered nurses have typically been underutilized as members of the primary care team. Leaders in health care have recognized that registered nurses have a unique set of skills that can enhance the effectiveness of the healthcare team. Registered nurses can provide delegated care for episodic and preventive care, chronic disease case management, care coordination, transitional care management, and other primary care functions. The aim of this project is to enhance the role of the primary care registered nurse in rural Kentucky by recruiting and training undergraduate nursing students to practice in community primary care teams. Additional aims are to increase access to care and address the healthcare needs of patients in rural and underserved communities with an emphasis on chronic disease prevention and control, including mental health and substance use conditions. To achieve the aims of this project, a primary care enrichment program was created to educate BSN students to assume leadership and practice roles in primary care. The University of Kentucky College of Nursing partnered with the University of Kentucky Center of Excellence in Rural Health, Appalachian Regional Healthcare and Southeast Area Health Education Center to assist with achieving the goals of the project.

The goals of the primary care enrichment program are to 1) enhance BSN students’ knowledge and clinical skills in primary care and 2) improve the screening and management of patients with chronic health problems, including screening for behavioral health and substance use conditions. Students apply and are selected for the program based on a GPA of 3.0 or above and an essay describing their interest practicing in primary care in rural and underserved areas. Students who are selected receive an annual stipend and are required to enroll in four 1-credit-hour online seminars over the course of the program. Students are also required to complete 240 clinical hours in a primary care clinic in a rural, underserved area in southeastern Kentucky.

Seminars topics include the social determinants of health; role of the registered nurse in primary care; primary, secondary, and tertiary prevention strategies; mental health and substance use screening; quality and safety; managing populations; tracking outcomes; evaluation; and billing and reimbursement. In the primary care clinical setting, students are precepted by registered nurses and advanced practice registered nurses. Outcomes achieved thus far, development of the primary care enrichment seminars, student clinical experiences, lessons learned, and future plans for the primary care enrichment program will be discussed.

This project is supported by the Health Resources and Services Administration (HRSA) of the US Department of Health and Human Services (HHS) under grant number UK1HP31708 Enhancing the Role of the Primary Care Registered Nurse in Rural Kentucky, $1,770,319. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the US Government.

P20 - Using a Fishbone Diagram to Assess and Remedy Barriers to Utilization of a New Registered Nurse (RN) Role in a Federally Qualified Health Center (FQHC)

Updated: 07/20/20

Background: Increasingly, registered nurses (RNs) are incorporated into primary care teams. Yet there is wide variability in nursing roles and responsibilities across organizations. Policy makers and federal agencies (i.e. Health Resources and Services Administration [HRSA]) are urging in-depth examination of RN utilization in primary care. Currently, limited research exists that describes how primary care agencies learn to incorporate RNs into their care teams. Our 4-year HRSA–funded project seeks to enhance the use of RNs in primary care to the full scope of their licensure. The purpose/learning outcome for this presentation is to describe how the use of a fishbone diagramming process has begun to identify the root causes of limited utilization of a new RN role to advance the goals of one federally qualified health center (FQHC).

Methods: A quality improvement project is being conducted to assist a FQHC to enhance the practice scope of a new RN recently added to the primary care team. Led by the grant team, clinical team members utilized a fishbone diagram methodology (a.k.a., a cause-and-effect diagram) as the initial step to diagram the root causes behind the underutilization of the new RN. This exercise can help a team identify the most significant factors that influence the key factors limiting the use of the RN. By naming these potential root causes, the team and FQHC staff can be better poised to focus its efforts on the areas that will provide the greatest leverage for change.

Results: Preliminary data from the fishbone diagram process will be provided. Initial brainstorming with key informants suggests that the FQHC faces several barriers to actualizing the use of a RN to the full scope of her license. The barriers fall into four major categories: leadership knowledge/”buy-in,” finances, space, and clinic staffing. Regarding “buy-in”: the leadership at this FQHC actively aims to enhance its quality measures and its primary care medical home (PCMH) status, yet may not see the link between the use of a RN and these goals. Regarding finances, the administrative leadership describes these as a reason to limit the use of the RN. On space limitations, the staff describe this as an impediment to incorporating RN chronic care and transition management, and RN patient education in the clinic. The nursing leadership is aware of the benefits of an RN, but the clinic team is unaware of best practices within the RN scope of licensure to achieve staff, clinic and leadership goals.

Conclusions: As healthcare organizations seek to provide value-based care, full knowledge of the essential role of the RN in quality improvement and team-based care delivery is vital. The fishbone diagram exercise allowed this vital FQHC’s team members to identify the root causes around the problem of underutilization of the RN. It also helped the team to identify and launch RN role and team workflow changes.