8/11/2015. Role of the ANP in Translating Evidence to Practice. Identification of a Gap/Issue/Need

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1 Utilizing an Advanced Practice Nurse Led Transitional Care Model to Improve the Health Outcomes of High Risk Elders with Heart Failure Living at Home In Western New York Linda L. Steeg DNP, RN, MS, ANP-BC Role of the ANP in Translating Evidence to Practice AACN Essential I: Scientific Underpinnings for Practice address current & future practice issues based upon current evidence AACN Essential II: Organizational & Systems Leadership for Quality Improvement & Systems Thinking AACN Essential VI: Inter-professional Collaboration for Improving Patient & Population Health Outcomes AACN Essential VIII: Advanced Nursing Practice Identification of a Gap/Issue/Need Fragmentation of care: A gap in our current healthcare delivery system An analysis of Medicare expenditures in % of Medicare beneficiaries were re-hospitalized within 30 days of their initial admission 34% of Medicare beneficiaries were re-hospitalized within 90 days (Naylor 2011) 50.2% of these Medicare beneficiaries who were rehospitalized within 30 days had no bill for a visit to a physician s office within those 30 days (Jencks, 2009) 1

2 Significance Findings of the Medicare Payment Advisory Board (MedPAC) % of readmissions to the hospital for Medicare beneficiaries within 30 days were preventable 64% of the Medicare beneficiaries who were readmitted in 2007 had received no post-acute care following discharge An estimated $15 Billion dollars was spent in 2007 for churning (CMS 2007) An estimated $25- $45 Billion dollars was spent in 2011 on unnecessary hospital readmissions and avoidable complications (Health Affairs 2011) Multiple initiatives and healthcare programs and agencies have begun to address the quantitative and qualitative costs of churning Transitional Care Programs have been identified as innovative solutions aimed at addressing churning Various Models of Transitional Care Initiation of services prior to the patient s discharge from the hospital Timely post-discharge follow-up for patients and caregivers Assessment of the patient s post-discharge status Timely medication reconciliation Engagement of patient and caregiver(s) in plan development Self-care management support for patient and caregiver(s) Linkage to community support services Transition back to the PCP ( 2010 Affordable Care Act U.S. Section 3026) Key Components of the TCM #1. Pt. Centered Care/Self Care Empowerment & Self-Efficacy #2. Tools for Self Care Management Symptom Recognition & Self Care Management #3. Medication Management Medication Reconciliation Medication Adherence #4. Time Limited Transition individual back to the PCP (Naylor 1989) 2

3 The Capstone Question Was care delivered by Advanced Practice Nurses (APNs) to high risk elders with Heart Failure living at home in Western New York from consistent with the established American Academy of Cardiology Fellows (ACCF) & American Heart Association (AHA) 2009 Guidelines for the Diagnosis and Management of Heart Failure in Adults and address the four Clinical Practice Categories identified in the Omaha Classification System? Specific Aims 1. To determine if high risk Elders with Heart Failure who received inhome follow-up by APNs were managed in accordance with the established 2009 ACCF/AHA Clinical Practice Guidelines for the Diagnosis and Management of Heart Failure in Adults. 2. To determine if care delivered at home by APNs to high risk Elders with Heart Failure addressed the Four Clinical Practice Categories identified in the Omaha Classification System. 3. To determine if Medication Reconciliation was completed during the initial in-home visit as well as during subsequent in-home follow-up visits. 4. To determine if Elders with Heart Failure followed by APNs at home required readmission to hospital for exacerbation of Heart Failure symptoms at 30 days, 60 days, and 90 days post-discharge. 5. To determine if Elders followed by APNS at home required Emergency Room evaluation for exacerbation of Heart Failure symptoms within 30 days, 60 days and 90 days post-discharge. Bandura s Social Cognitive Theory SCT is used extensively in Healthcare and is especially applicable when: implementing programs aimed at changing behaviors applying new knowledge to practice SCT identifies multiple factors which impact an individual s ability to change including: Personal factors Attributes of the behavior itself Environmental influences Perceived ability to change Perceived self-efficacy. (Bandura 1986) 3

4 Study Design This descriptive pilot study evaluated the care delivered by APNs to Elders with Heart Failure living at home in Western New York (WNY) from Clinical Practice Guidelines for the Management of Heart Failure in Adults (ACCF/AHA 2009) Four Clinical Practice Categories of Care defined in the Omaha System. Convenience Sample Methods Medical records were de-identified and assigned an individual Case number (Case #1-15) Each visit completed in a 12 month period from for each of the 15 cases was used in the statistical analysis Data points were selected from established tools, including the evidenced based CPG ( ACCF/AHA 2009) and the 4 clinical Practice Categories from Omaha Classification System The Data Collection Tool included three components : Demographics ACCF/AHA 2009 Clinical Practice Guidelines for the Management of Heart Failure in Adults Four Clinical Practice Categories defined in The Omaha System. Study Design This descriptive pilot study evaluated the care delivered by APNs to Elders with Heart Failure living at home in Western New York (WNY) from Clinical Practice Guidelines for the Management of Heart Failure in Adults (ACCF/AHA 2009) Four Clinical Practice Categories of Care defined in the Omaha System. 4

5 Data Analysis of the Specific Aims Demographicsof the Sample Data Analysis Accordance with ACCF/AHA 2009 ClinicalPractice Guidelinesfor the Managementof Heart Failure in Adults (Specific Aim #1) Applicationof the 4 ClinicalPractice Categoriesin the Omaha Classification System (Specific Aim #2) Evidence of MedicationReconciliationand MedicationDecision Making (Specific Aim #3) Readmissions to hospital for evaluation of exacerbation of Heart Failure symptoms at 30 days, 60 days and 90 days post-discharge (Specific Aim #4) Visits to the Emergency Departmentfor evaluationof exacerbationof Heart Failure symptomsat 30 days, 60 days and 90 days post-discharge (Specific Aim #5) Tools for Data Collection Demographics Tool Age, Gender, Ethnicity, Zip Code; Insurance, Educationallevel, SocialSupport, Use of SupportServices, Time to Readmissionor visits to ED for exacerbationof symptomsof Heart Failure symptoms,primary AdmissionDiagnosis; Number of Comorbiditiesand Number of APN visits in 12 months ACCF/AHA 2009 Clinical Practice Guidelines for the Management of Heart Failure in Adults: 6 Critical Aspects for Post-Discharge Management Medicationreconciliation /& MedicationDecision Making Diet Activity Level Daily Weights Educationof the patientand caregiver(s) regarding symptomrecognitionand management Need for follow -up appointmentswith the Primary Care Provider The Omaha System: 4 Clinical Practice Categories Surveillance & Monitoring Teaching/Guidance/Counseling Treatmentsand Procedures Case Management Table #1 Patient Age in Years of High Risk Elders with Heart Failure living at home I in WNY (n=15) Age Frequency Table #3 Number of APN Visits to high risk Elders with Heart Failure living at home in WNY (n=15) N= 15 Mean of Visits 8.67 Std. Deviation 3.31 Range 4-14 Results: Demographics Table #2 Descriptive Characteristics of High Risk Elders with Heart Failure living at home in WNY (n=15) n=15 Age Mean =82 Range Gender Frequency Male 1 Female 14 Ethnicity African American Asian Caucasian Hispanic Native Americans Total Zip Code City Suburban Total Social Support Lives alone Lives with Primary Caregiver Lives with Someone other than Primary Caregiver Lives in Assisted Living Facility Total

6 Frequency of APN Visits & Readmissions & ED Visits Case Number Actual # APN Visits Actual # Hospital Readmissions > 90days Total Actual # ED Visits Results: : Table # 7 Adherence to ACCF/AHAClinical Practice Guidelines for the Management of Heart Failure in Adults (Specific Aim #1) Documented Not Documented Chi Square Level of Significance p=.05 Med Reconciliation No Readm it Readmit No Readmit Readmit Chi-Square df Diet Weight CPG Results Medication Reconciliation No- readmission Cases (n=10) Documented = 110 visits Not documented= 12 visits Readmitted Cases (n=5) Documented =36 visits Not documented= 7 visits Chi-square analysis comparing the NO readmission Cases with the Readmission Cases found a NON-Statistically Significant Chi Square value of x2=1.295 ( level of significance=<.05) Diet No- readmission Cases (n=10) Documented= 72 visits Not Documented=20 visits Readmitted Cases (n=5) Documented= 28 visits Not Documented=10 visits Chi-square analysis comparing the NO readmission Cases with the Readmission Cases found a NON- StatisticallySignificantChiSquarevalueof x2=.0639 ( Levelof significance=<.05) Weight Monitoring No readmission Cases (n=10) Documented= 42 visits Not Documented= 11 visits Readmitted Cases (n=5) Documented=32 Not Documented=4 visits Chi-square analysis comparing the NO readmission Cases with the Readmission Cases found a NON- Statistically Significant Chi Square value of x2= ( Level of significance=<.05) 6

7 CPG Results Con t. Activity Level Each Case was described according to the maximal level of functional status Activity Level 0= non-ambulatory ( bed to chair) Activity Level 1 = ambulatory about home; performs ADL s Activity Level 2= ambulatory, completes ADL s and exercises routinely 33% of Cases were non-ambulatory 60% of Cases were able to ambulate about home & perform ADL s Only 1 Case scored Activity Level 2 Identification & Management of Symptoms Early symptom recognition was challenging 1 of 15 Cases had tele-monitoring 5 of 15 Cases lived alone & self managed their care without support services 5 of 15 cases had co-morbidity of Advanced Dementia 3 of 15 were non-ambulatory (excludes assessment of activity intolerance) Follow-up with PMD Transitional Care intended to Bridge the Gap NOT intended to replace the PMD 53% ofcases weremanagedbytheaprnas thepcpdueto theirhomeboundstatusortheir co -morbidity of advanced dementia Results: Omaha Classification System (Specific Aim # 2) Bowles and colleaguesfrom Universityof Pennsylvania have studied the link betweenapn Interventionsand APN time spent on each of the 4 Omaha ClinicalPractice Categories Surveillance (66%) Detection of Symptoms : 92%-100% Analysis of Medication Decisions: 75%-100% Teaching/Guidance & Counseling ( 20%) Identification of Worsening Symptoms:: 92%-100% Symptoms Management Strategies: 67%-100% Case Management (14%) Care Coordination: 75%--100% Advocacy on Patient s Behalf : 31%-100% Treatments& Procedures (< 1%) Wound & Skin Care (n=5) 7%-83% Medication Set-up (n=6) 7%-43% (Bowles 2000) Limitations Novice PI Not Generalizable Small sample size n=15 Limited Geographicregion Short Timeframe: 12 months Limited access to patient records All Data coded as Nominal data Data collection was Labor intensive Manuallycollectedfrom hand written medical records Data collectiontool was not designedconcurrentlywith documentation tools Potential Evaluation Bias 7

8 Strengths Issue Addressed: Churning is a high volume, high risk, high cost issue in the healthcare system in the US Model & Tools Utilized: TCM is an established model used in multiple RCT s in the past 20 years across various vulnerable populations ACCF/AHA2009 Clinical Practice Guidelines for the Management of Heart Failure in Adults represents the current evidenced based practice guidelines & is the considered the gold standard The Omaha Classification System is recognized as a comprehensive, reliable and valid system to plan, implement and evaluate nursing care. Large data set Provides opportunities for further study No missing data Ability to recode data set as Categoricalfor further statistical analysis Implications for Clinical Practice: Findings from this pilot can be used to support the initiation of an APN Led Transitional Care Program for vulnerable elders in living at home in WNY. Implications for Clinical Practice APNs possess the advanced theoretical knowledge base and advanced assessment skills which position them to implement EBP guidelines APN possess the content expertise which provide credibility, legitimacy and a level of trust with other members of the interdisciplinary team Implementation of TCM has demonstrated the ability to facilitate timely application of research to clinical practice contributing to improved patient outcomes including: Decreased Churning Decreased Readmissions at 30, 60,90 days Decreased number of Visits to ED Opportunities for initiation of APN Led Inter-professional Transitional Care Programs for vulnerable high risk individuals Implications for Public Policy 2010 ACA: : Increase number of healthcare providers to meet the increased demand for provision of healthcare services 2010 IOM Report: Perform professional role at the highest level of education CMS (2012) Medicare Physician Fee Schedule Final Rule Reimbursement Codes for Transitional Care Services provided by APN s/pa s and MD s and Care Coordination Codes for services provided by RN s. 8

9 Conclusions APNS have demonstrated the ability to keep people well over time (Broten 2002) This Pilot Project has demonstrated that care delivered by APNs to Elders with Heart Failure living at home in WNY was consistent with the 2009 ACCF/AHA Clinical Practice Guidelines, as well as the Clinical Practice Categories of the Omaha Classification System. Further, this Pilot Project demonstrated ongoing Medication Reconciliation and ongoing medication decision making/treatment plan adjustment (Surveillance) was provided by the APN at the point of care. Finally, care delivered by the APNs to the elders in this Pilot Project was effective in eliminating readmissions at 30 and 60 days post Thank You 9