Thursday, August 28, 2014

Team-Based Interdisciplinary Care

This blog post originally appeared on the RWJF Human Capital Blog


The Robert Wood Johnson Foundation’s (RWJF) LEAP National Program is working to create a culture of health by discovering, documenting and sharing innovations in the primary care workforce. To advance this goal, the program is holding a series of six webinars that highlight best practices. (Read a post summarizing the first of the six webinars.) The second of the webinars in the series focused on team-based care for complex cases. Presenters included leaders from four primary care sites around the country that the LEAP program has deemed exemplars.

Managing Care for the Most Complex Patients

Kathy Bragdon, RN, director of care management at Penobscot Community Health Center in Bangor, Maine, discussed the rapid growth of the health center, and went on to describe its system of care management for the most complex patients.

The center relies on a transitions care manager, who shares information back and forth with the hospital and with patients’ medical homes. In addition, the manager meets with patients when they are in the hospital, looking to identify potential barriers to recovery and to provide any needed referrals.

“One of the big roles—we didn’t realize how big—was that a tremendous number of patients had no primary care at the time of admission,” she said. “We worked really closely with the hospitals trying to provide those services and make that linkage to those patients who needed primary care providers.”

Bragdon explained that the center’s biggest initiative was to embed care management at its larger facilities, using nurses, medical assistants, health coaches and social workers focused on improving patients’ self-management skills, thus reducing the number of hospitalizations and readmissions, and improving the overall quality of care. The initiative is built around face-to-face visits, as well as phone calls with a focus on hospital follow-up. They try to reach every patient within 72 hours after they’ve been discharged from acute care.

Finally, the center uses a community care team (CCT) to work on its most complex cases. In addition to the supports provided via embedded care management, the CCT conducts a team visit that includes both a social worker and a nurse, meeting the patient where it is convenient for them—at a doughnut shop, a homeless shelter, or wherever else makes sense. “We do this because the RN and the social worker look at the situation through very different eyes in trying to see what is driving that person to the emergency room,” she explained, adding that the effort is “focused on the highest utilizers of health care dollars.”

The cost savings generated by the CCT program are significant, she said, cutting costs to the state in half.

The Integrated Care Team

From Daughters of Charity Health Centers in New Orleans, Roslyn Arnaud, RN, chief nursing officer, and Grace Mena, RN Care Manager, discussed the center’s Integrated Care Team. Arnaud began by sketching out the members of the team. They include:
  • An RN Care Manager, who identifies patients who are not being treated appropriately by a primary care provider, generally at-risk patients with comorbidities. The nurses respond to patients from local safety net hospitals and provide intense follow-up support for them after discharge. They help patients understand what took place and make sure they have medications, have a follow up appointment with their primary care provider and reconcile medications. The RN Care Manager is also responsible for monitoring and tracking patients on anticoagulation therapy.  Additionally, they are responsible for overseeing the tracking of abnormal cancer screens.
  • A Patient Care Coordinator, who provides administrative support, including making appointments for patients for services the Health Center does not have provide onsite. Coordinators also make sure patients know about their appointments and work to ensure that they go. They also ensure that preventive care is completed, including mammograms, colonoscopies, pap smears, and other cancer-tracking.
  •  A Behavior Health Social Worker, who serves as a consultant to the patient, helping them identify the need for change, and establishing goals that are appropriate for that patient.
The team members also collaborate with a local university to arrange for the services of a clinical pharmacist and a certified asthma educator.

Mena explained that the center is now testing a team model with a different composition, bringing together a physician, nurse practitioner, medical assistant and care coordinator, with social workers also available to patients. She noted that the nurse practitioner provides patient education and patient engagement.   “The key part of this work is communication between the nurse practitioner and RN care manager,” she said.

Continuity and Coordination of Care for Complex Patients

Larry Holly, MD, CEO of Southeast Texas Medical Associates, then discussed his six-site clinic’s efforts to care for complex patients as they transition from one setting to another.

He said that the care transition process begins at hospital admission, when the patient receives a care plan to transition from the ambulatory to in-patient setting. Then, at the end of their hospital care, the patient receives materials that detail necessary follow-up appointments and include a medication reconciliation plan. Associates follows that up with a “care coaching call,” and then the patient completes the process with a follow-up appointment at the clinic.

Associates also uses a Hospital Consumer Assessment Health Care Provider and Systems audit that assesses whether the care provided has been patient-centered and of sufficient quality. It asks whether the physician explained the care plan, answered all of patient’s questions without interrupting, inquired about whether care at home was adequate, and wrote down what potential symptoms would necessitate a return to the hospital. The clinic reviews results of the assessment with the hospital.

Associates also features a Care Coordination Department that identifies and tries to overcome barriers to care, Holly explained. So if patients lack transportation to appointments, can’t afford their medication, or are in need of dental care, the patient is referred to other resources.

Said Holly: “This system has integrated a number of complex problems that have befuddled physicians for years. Now we can easily provide those in the context of continuity of care and transitions of care for complex patients. These are critical parts of a medical home.”

Expanding the Team for Complex Cases

Craig Robinson, MPH, executive director of Cabin Creek Health Systems (CCHS), and Amber Crist, MS, CCHS director of education and program development described their efforts to treat patients with chronic pain using interdisciplinary teams.

CCHS has four sites in rural southern West Virginia, Robinson and Crist explained. The program began with an effort to identify older, frail patients in the area in need of care focused on reducing pain from chronic conditions.

“We quickly realized [such patients] increase the complexity of our system,” Crist said, going on to explain that the system needed to adapt. “We needed to expand our clinical team. It couldn’t just be the medical provider. Accordingly, the team grew to include the MD, a nurse practitioner, a physician assistant, a medical assistant, a behavioral health coach, a pharmacist, a health coach, and administrators.”

“If we can keep these patients out of the hospital, we save the system money. That’s where the suffering, is and that’s also what’s sometimes burning our staff out,” she said. “Our providers feel alone in the room. [Otherwise,] they feel they don’t have anyone else to turn to and are alone dealing with these complex patients.”

The RWJF Human Capital Blog will report on additional LEAP webinars in coming weeks.

Friday, August 22, 2014

More Nursing Schools Focus on Interdisciplinary Care

A number of the nation’s top nursing schools now require students to participate in at least one interprofessional education course or activity, according to a “dashboard” report recently released by the Future of Nursing: Campaign for Action, an initiative of RWJF and AARP.

Experts have been calling for interprofessional education for decades, but more schools are now responding because requirements are being written into health professions accreditation standards, Barbara Brandt tells RWJF’s Sharing Nursing’s Knowledge (SNK) newsletter. Brant is head of the National Center for Interprofessional Practice and Education, a public-private partnership supported by RWJF, the U.S. Health Resources and Services Administration, and other organizations. While there is not yet any comprehensive data quantifying the number of interprofessional activities and courses offered nationwide, Brandt said that there is “no question” the number of schools requiring these types of activities is growing rapidly.

INQRI is credited in the SNK article for helping to foster interdisciplinary research and collaborative practice. The ongoing impact can also be seen in health journals, where the number of articles in 10 of the top health services research journals co-authored by a registered nurse (RN) is increasing dramatically, according to a supplemental dashboard indicator, which shows that articles co-authored by RNs jumped from 80 to 145 from 2010 to 2012.

“For much of history, physicians made the major care decisions,” INQRI Grantee Joanne Spetz said. “We need to start teaching nursing students that they bring a set of skills to the table that are unique and distinct, and add value to the skills provided by other professionals. That will help them develop good, collaborative relationships over time.”

Monday, August 11, 2014

Hourly Rounds Schedules for Nurses Improve Patient Satisfaction

A nurse-led study at an acute-care hospital in Houston found that overall patient satisfaction may be improved when nurses adopt hourly rounds schedules, but more research is needed to clearly define the benefit of hourly rounds to patients. The study was conducted at St. Luke’s Episcopal Hospital, where nurses on one unit engaged in a standard hourly rounding process to see if it would improve efficiencies, patient satisfaction, and quality and safety metrics, reports EndoNurse.

The study, published in National Association for Healthcare Quality’s Journal for Healthcare Quality, is based on data collected over six months in two 32-bed cardiovascular surgery nursing units at the hospital. Nurses on the control unit proceeded with rounds as they had before. The research team was led by Rebecca Kreppler, a professor at the College of Nursing at Texas Women’s University in Houston.

The team examined weekly readmission rates, number of patient falls, patient satisfaction questionnaires, the number of steps nurses walked in a shift (to measure efficiency of care), total number of call lights used by patients, and a nursing staff survey.

The most significant difference between the two units was in how often patients used their call lights. Patients in the intervention unit used their call lights less than patients on the control unit, and also indicated in surveys that they were satisfied with how quickly call lights were answered. Kreppler noted however, that because hourly rounding was only one of several quality improvement strategies employed in the units, more research was needed to see the direct impact it may have on patient outcomes, according to Endo Nurse.

Thursday, July 31, 2014

INQRI’s Mark Pauly Co-Authors New Study on Dual MBA/MD Degrees

Physicians who have both doctor of medicine (MD) and master of business administration (MBA) degrees reported that their dual training had a positive professional impact, according to a new study co-authored by INQRI co-director Mark V. Pauly. The study was published online by Academic Medicine and is one of the first to assess MD/MBA graduates’ perceptions of how their training has affected their careers. It focuses on physician graduates from the MBA program in health care management at the University of Pennsylvania.

The MD was more often cited as conveying professional credibility, while 40 to 50 percent of respondents said the MBA conveyed leadership, management, and business skills. Respondents also cited multidisciplinary experience and improved communication between the medical and business worlds as benefits of the two degrees.

The study’s authors also include David A. Asch, co-director of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars Program at the University of Pennsylvania and Clinical Scholar Mitesh S. Patel, who was quoted in a statement:

“A study published in 2009 found that among 6,500 hospitals in the United States, only 235 were run by physicians. Moving forward, changing dynamics triggered by national health care reform will likely require leaders to have a better balance between clinical care and business savvy. Graduates with MD and MBA training could potentially fill this growing need within the sector.”

Read the study, “The Role of MD and MBA Training in the Professional Development of a Physician: A Survey of 30 Years of Graduates From the Wharton Health Care Management Program,” which will also be published in the September issue of Academic Medicine.

The study was also covered on the RWJF Human Capital Blog.

Friday, July 25, 2014

New Guidance Shows Importance of Evidenced-Based Best Practices in Hygiene

A new guidance published in the August issue of Infection Control and Hospital Epidemiology emphasizes the importance of proper hand hygiene to prevent the spread of health care-associated infections, reports Health Canal. RWJF Health & Society Scholars program alumna Allison Aiello and her colleagues developed the guidance, which includes a series of evidenced-based best practices for optimal hand hygiene in health care settings. The guidance encourages increased availability and acceptability of certain soap and alcohol-based rubs and the development of a system to empower health care personnel to create a personalized hygiene system that gives them a way to track their progress.

The recommendations include developing a multidisciplinary team in which representatives from administrative and unit-level leadership work together to establish a hand hygiene program that best fits each institution. The program should include clear performance targets and an action plan for improving adherence, according to the guidelines.

An INQRI-funded study published last year in Critical Care Medicine found that a nurse-led intervention combining a “bundle” of evidence-based practices with a comprehensive safety program dramatically reduced the mean rate of health care-associated infections. The study was conducted by David Thompson and Jill Marsteller associate professors at Johns Hopkins University in the School of Medicine and Bloomberg School of Public Health, respectively, and by J. Bryan Sexton now at the Duke University Health System Patient Safety Center.

Friday, July 18, 2014

Nurses Lead Innovations in Geriatrics and Gerontology

This story originally appeared in the July 2014 issue of Sharing Nursing's Knowledge, a monthly email newsletter from the Robert Wood Johnson Foundation.

Nurse-led initiatives are intended to help the nation’s health care system prepare for a crush of elderly people with multiple chronic conditions.

Nurses have been leading health care innovations since the dawn of the profession. They have ushered in broad-scale changes in areas ranging from better hygiene practices for wounded soldiers to public health visits to overcrowded urban homes to reproductive health services for women.

In more recent decades, nurses have begun developing innovations in geriatric care to help meet the massive health care needs of an aging population. They are finding new ways to improve the quality of care for older adults and ensure that it takes family and community considerations into account; improve access to highly skilled health care providers with training in geriatrics; narrow disparities that disproportionately affect older minorities; avoid preventable hospital readmissions; and more.

Their work answers the call from a groundbreaking report on the future of nursing that was released in 2010 by the Institute of Medicine (IOM). It urges nurses to continue their long legacy of innovation “as the health care needs of the population change from acute and infectious disease to that of an aging population with chronic disease.”

The country is, indeed, undergoing dramatic demographic changes. As Baby Boomers age and immigration patterns change, America is becoming older and more diverse. By 2050, the number of Americans age 65 and older will hit 40 million, about 20 percent of the population, according to the U.S. Census Bureau. These changes will strain the health care system and the nursing profession, the largest segment of the health care workforce.

Experts say the nursing workforce is not adequately prepared for a crush of elderly patients who are living longer, and sicker, with more chronic and complex health conditions. To meet these growing health care demands and bridge gaps in services for older Americans, the IOM said nurses “must continue to develop innovative care models based on current successes” in rural aging and other areas.

Fortunately, many nurses are already leading efforts to meet current and future health care needs. “Nurses are beginning to home in on the chronicity and the larger number of older people coming down the pike,” said Jennie Chin Hansen, RN, MS, FAAN, CEO of the American Geriatrics Society and a member of the study committee supported by the Robert Wood Johnson Foundation (RWJF) that drafted the IOM’s nursing report.

She pointed to the Transitional Care Model, developed by Mary Naylor, RN, PhD, FAAN, national program director for RWJF’s Interdisciplinary Nursing Quality Research Initiative (INQRI). The model utilizes nurses to reduce hospital readmissions among elderly patients after they have been discharged from the hospital. As many as one-third of re-hospitalizations are considered preventable, so reducing readmissions not only improves patients’ quality of life, but reduces health care costs.

The Program for All-Inclusive Care for the Elderly (PACE) is an example of a nurse-driven innovation in geriatric care. A replication of a program spearheaded many years ago by Chin Hansen, PACE is a now a federally legislated program in which interdisciplinary teams of providers give frail elders coordinated health, medical, and social services support by a one-stop system, a process that enables many to live in their own homes for longer periods of time.

Another nurse-led innovation, Nurses Improving Care for Healthsystem Elders (NICHE), was developed to better meet the needs of older adults in a health care system that, in general, lacked access to gerontology-trained providers and to care coordination services. The NICHE program is helping hospitals and, increasingly, community health systems, provide older Americans with “sensitive and exemplary care.” Under the program, “nurses are empowered by knowledge to provide high-quality care for older adults and, in doing so, teach others about the uniqueness of caring for older adults,” said Tara Cortes, PhD, RN, FAAN, executive director of the Hartford Institute for Geriatric Nursing in New York and an alumna of the RWJF Executive Nurse Fellows program (1999-2002).

And that’s just the beginning:


Promoting cancer screening among older African American women

Nurses all over the country are studying ways to improve care for older Americans. In North Carolina, for example, Dee Baldwin, PhD, RN, FAAN, a nurse educator at the University of North Carolina-Charlotte and an RWJF Executive Nurse Fellows program alumna (2000-2003), has spent decades exploring ways to prevent cancer in older African American women, who are more likely to die from the disease than other groups.

In 1992, Baldwin launched Project Breast Health, a culturally sensitive educational program to encourage more African American women to take advantage of cancer screening services. She also led an effort to hire lay navigators to raise awareness about breast and cervical cancer among older women in African American communities and developed electronic computer messaging to target the population. “We tried to look at different ways to reach people.”


Improving the quality of care in assisted-living facilities

Anna Beeber, PhD, RN, an RWJF Nurse Faculty Scholar (2011-2014) also from North Carolina, is exploring ways to improve the quality of care in assisted-living facilities. She is conducting research that examines staffing, service delivery, and resident outcomes in order to help assisted-living communities better match services with resident needs. “We really don’t know in assisted-living communities what, if any, influence nurses have on quality of care,” she says. And that is a critical piece of information that has the potential to improve care for the roughly 1 million Americans who currently live in the country’s 22,000 assisted-living facilities.

Increasing the number of geriatrics-trained nurses

In North Dakota, Jane Strommen, PhD, project coordinator of the North Dakota Gerontology Consortium, an initiative supported by Partners Investing in Nursing’s Future (PIN), is working to ensure that older people have more access to geriatrics-trained nurses. She and her team are promoting gerontology nursing via marketing materials, nursing conferences, nursing-themed summer camps, and stipends for nurses and nurse educators who study gerontology and geriatric nursing. “We have a growing population of older adults in our state, and we know the need for nurses who have the skills and training to care for them is just going to increase,” she says.

Creating safer homes


And in Maryland, Sarah Szanton, PhD, ANP, an RWJF Nurse Faculty Scholar (2011-2014) and associate professor of nursing at Johns Hopkins University, has come up with an innovative program to use “handymen” to turn older people’s homes into safe environments. Her goal is to enable elderly people to continue living in their homes as long as they are willing and able—and to stay out of nursing homes, which create considerable taxpayer expense. Read more about Szanton’s work here.

These projects are among the many nurse-led efforts under way across the nation to improve care for older Americans—a natural outgrowth, Chin Hansen says, of nurses’ skills, abilities, and population focus. “One of the things that nurses have always done is advocate for the patient and the family,” she says. They will continue to do that as their patients get older, and they will likely have a greater ability to transform health care as more earn master’s and doctoral degrees and assume positions of leadership in health care and society. Says Chin Hansen: “More nurses are being sought out for their leadership and their ability to change the current culture of medical care towards health and health care in an aging America.”

Tuesday, July 15, 2014

Collaboration, Communication Needed Between Nursing, Pharmacy Staff

Medication management decisions must be made with clear communication and collaboration between the nursing and pharmacy departments to avoid errors and negative patient outcomes, according to a recent Advanced Healthcare Network for Nurses article written by Executive Nurse Consultants Robin Fowler and Kevon Garrison of Aesynt, a company providing pharmacy automation technology and systems. Additionally, each hospital must find a medication distribution model that fits with its workflow and nurse leaders should have a strong voice in its selection. They write:

“The use of pharmacy technology is important to strategically improving the medication management process, but if decisions are made without nursing input, there can be unforeseen consequences. ... When the pharmacy and nursing departments meet frequently and all stakeholders are focused on the same end-goal, the outcome is a medication management model that produces fewer errors, greater efficiency and better patient outcomes.”

An INQRI-funded study examined acute care hospitals to determine the relationships among characteristics of the nursing practice environment, nurse staffing levels, nurses’ error interception practices, and rates of nonintercepted medication errors. The study, “Nurses’ Practice Environments, Error Interception Practices, and Inpatient Medication Errors,” was published in the June 2012 issue of the Journal of Nursing Scholarship and found that nurses’ error interception practices are associated with lower rates of nonintercepted medication errors.

The INQRI study also found that a supportive practice environment—reflected in factors including teamwork and nurses’ opportunities to participate in hospital- and unit-level decisions—is associated with a higher quality of nursing care.

The study was conducted in a sample of 82 medical-surgical units recruited from 14 U.S. acute care hospitals in New Jersey, and included 686 registered nurses.Linda Flynn and Dong-Churl Suh led the research.