Objectives. Background and Significance. Method. National Nursing Initiatives. National Nursing Initiatives. Transition Management

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1 Utilizing the QSEN Framework to Structure : Registered Nurse Care Coordination and Transition Management Sheila Haas, PhD, RN, FAAN Beth Ann Swan, PhD, CRNP, FAAN Traci Haynes, MSN, RN, BA, CEN Objectives Describe development of the care coordination and transition management (RN-CCTM) model. Discuss dimensions and outcomes of the RN-CCTM model. Describe the use of QSEN to standardize role expectations, education, and evaluation of the RN-CCTM model. Discuss use of RN-CCTM dimensions, competencies, and evidence-based tools and methods to impact patient outcomes. Background and Significance Health care delivery is shifting from inpatient to outpatient and community settings. Need for care coordination and management of transitions between types of care, providers and settings is often overlooked, episodic, follows specialty rather than primary care. Care coordination and transitions occur with no one accountable for coordinating care or managing transitions. Roles of RNs: National Nursing Initiatives American Academy of Ambulatory Care Nursing (AAACN) Expert Panels Core Curriculum for Care Coordination and Transition Management In the context of the interprofessional care team Method Develop RN Evidence-Based Competencies for Care Coordination and Transition Management Tap into expertise of ambulatory and acute care nurse leaders A cost effective, expeditious approach to bring leaders together Opportunities to dialogue and build on each individual leader s knowledge, skills and experience Use data summary techniques to capture and share outcomes achieved by each Expert Panel Roles of RNs: National Nursing Initiatives Expert Panel 1 Expert Panel 2 Expert Panel 3 Expert Panel 4

2 First Expert Panel Provided with results of a search in MEDLINE, CINAHL Plus, and PsycINFO that yielded 82 journal articles plus white papers available on line from major organizations 26-member panel worked in dyads and abstracted data to a table of evidence (TOE) Each dyad reviewed four to five articles and needed to reach consensus on items for TOE Then abstracted the information onto the template table of evidence First Expert Panel (cont d.) Expert Panel represented: Practice and Education; Public, Private, Military, and Veterans Organizations; 15 States in East, West, North, South, and Central United States Table of Evidence Template Literature Review Team Table of Evidence (TOE) 1. Authors of Study Column 2. Study Title Column 3. Research Questions Column 4. Research Design Type Column 5. Setting and Sample, Inclusion/Exclusion Criteria Column 6. Methods, Intervention and/or Instruments 7. Analyses Column 8. Key Findings Column 9. Recommendations Column 10. List dimension or dimensions identified with activity or activities that are supporting and/or contributing to care coordination and transition management Second Expert Panel 16-member panel was charged with: Defining the dimensions, identifying core competencies Describing the activities linked with each competency for care coordination and transition management in ambulatory settings Using focus group methods online, the expert panel identified nine patient-centered care dimensions and associated activities of care coordination and transition management

3 Second Expert Panel Outcome identified nine dimensions: 1. Support for self-management 2. Education and engagement of patient and family 3. Cross setting communication and transition 4. Coaching and counseling of patients and families 5. Nursing process including assessment, plan, implementation/intervention, and evaluation; a proxy for monitoring and intervening 6. Teamwork and collaboration 7. Patient-centered care planning 8. Decision support and information systems 9. Advocacy Competencies: Knowledge, Skills and Attitudes The Quality and Safety in Education in Nursing (QSEN) format was used for each care coordination and transition management dimension identified (Cronenwett et al., 2OO7) Panelists were also asked to identify the knowledge, skills, and attitudes identified in the literature, and if absent to use expert opinion to specify each This panel also identified competencies needed for each dimension including knowledge, skills, and attitudes. 13 Dimensions, Activities, and Competencies for Care Coordination and Transition Management Third Expert Panel Reviewed, confirmed, and created a table of dimensions, activities, and competencies (including knowledge, skills, attitudes) for ambulatory care RN care coordination and transition management After much discussion, they determined the original 8th dimension of decision support and information systems, as well as, telehealth practice were technologies that support all dimensions Population Health Management became the new 8th dimension given: The prominence it is assuming in outpatient care even though there was little discussion of it in the literature reviewed Dimensions of Care Coordination and Transition Management Expert Panel 2: 1. Support for self-management 2. Education and engagement of patient and family 3. Cross setting communication and transition 4. Coaching and counseling of patients and families 5. Nursing process including assessment, plan, implementation/intervention, and evaluation; a proxy for monitoring and intervening 6. Teamwork and collaboration 7. Patient-centered care planning 8. Decision support and information systems 9. Advocacy Expert Panel 3: 1. Advocacy 2. Education and engagement of patients and families 3. Coaching and counseling of patients and families 4. Patient-centered care planning 5. Support for self-management 6. Nursing process: proxy for monitoring and evaluation 7. Cross setting communications and transitions 8. Teamwork and collaboration 9. Population Health Management Care Coordination Definition Care coordination is the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patient s care to facilitate the appropriate delivery of health care services. Organizing care involves the marshaling of personnel and other resources needed to carry out all required patient care activities and is often managed by the exchange of information among participants responsible for different aspects of care. (McDonald et al., 2007 in AHRQ Care Coordination Measures Atlas, 2010, p. 4)

4 Naylor s Definition of Transitional Care Transitional care comprises a range of time-limited services that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at-risk populations as they move from one level of care to another, among multiple providers and across settings. (Naylor, 2000) Transition Management Definition: the ongoing support of patients and their families over time as they navigate care and relationships among more than one provider and/or more than one health care setting and/or more than one health care service. The need for transition management is not determined by age, time, place, or health care condition, but rather by patients' and/or families' need for support for ongoing, longitudinal individualized plans of care and follow-up plans of care within the context of health care delivery. (Haas, Swan, & Haynes, 2014, p. 3) Challenges with Care Coordination and Transition Management in the 90s Nurses in ambulatory care were performing Care Coordination and Transition Management role dimensions, but until this study (Haas et al., 1995) there was no evidence of their work or contribution Nurses typically did not chart in ambulatory on paper or EHR With advent of EHR, there are few documentation screens for nurse documentation There are no indicators to track impact that RNs make on processes or outcomes of patients in ambulatory care Growing Demand for Care Coordination and Transition Management for High Risk Chronic Care Populations Health care spending in the United States is disproportionate, half of U.S. health care dollars are spent on five percent of the population (Conwell & Cohen, 2002). 78% of health care spending is for persons with chronic conditions s/susan_norris_march% pdf Many struggle with multiple illnesses combined with social complexities such as, mental health and substance abuse, extreme medical frailty, and a host of social needs such as social isolation and homelessness (Berwick, Nolan & Whittington, 2008). Growing Demand for Care Coordination and Transition Management for High Risk Chronic Care Populations (cont.) Chronic disease combined with co-morbid mental illness present challenges in self-management, treatment adherence and cost effective care h% pdf Individuals with multiple needs are often unable to navigate the complex and fragmented health care. Care providers recognize the need for better coordinated care that leverages community resources and aligns social determinants such as food, housing and safe environments, but payment structures in the health care system do not allow such alignment (Freeman, 2006). New Role Development in Healthcare Involves: Responsiveness to a need within healthcare Grounding in and integration of best evidence-based practice Specification of Role Dimensions: major areas of responsibility and accountability Activities that comprise each dimension Performance Expectations or Competencies needed within each dimension: QSEN Knowledge, Skills and Attitudes (KSAs) was chosen

5 New Role Development in Healthcare Involves: Methods to specify the Role: Position description with reporting relationships Plan to educate for the Role: Development of standardized educational resources Evaluation plan for competencies prerequisite to role performance including: Plan for national recognition of competence Plan to evaluate outcomes of performance in the role Developing linkages between dimensions within the role and interface of role dimension practice with other members of the interprofessional healthcare team Vision for RN-CCTM CTM Model for Ambulatory Care Nurses Is consistent with recommendations of IOM (2011) Report - Future of Nursing: Leading Change Advancing Health 1) Nurses should practice to the full extent of their education and training. 2) Nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. 3) Nurses should be full partners, with physicians and other health care professionals, in redesigning health care in the United States. 4) Effective workforce planning and policy making require better data collection and an improved information infrastructure. AAACN CCTM Experts Karen Alexander, MSN, RN, CCRN Thomas Jefferson University Janine Allbritton, RN, BSN Baylor University Medical Center JoAnn Appleyard, PhD, RN University of Wisconsin, Milwaukee Jilll Arzouman, MS, RN, ACNS, BC, CMSRN, AMSN Treasurer University Medical Center Tucson Deborah Aylard, MSN, RN Core Physicians Deanna Blanchard, MSN, RN UW Health University of Wisconsin Elizabeth Bradley, MSN, RN-BC VA Pasco OPC Stefanie Coffey, DNP, MBA, FNP-BC, RN-BC The Villages, VA Outpatient Clinic Sandy Fights, MS, RN, CMSRN, CNE AMSN President Jan Fuch, MBS, MSN, NEA-BC Cleveland Clinic Patricia Grady, BSN, RN, CRNS, FABC Lahey Clinic Medical Center Jamie Green, MSN, RN Kaiser Permanente Denise Hannigan, RN-BC, MSN, MHA Cedars-Sinai Clare Hastings, RN, PhD, FAAN NIH Clinical Center Anne Jessie, MSN, RN Carillon Clinic Sheila Johnson, RN, MBA Dartmouth-Hitchcock Accountable Care Programs CDR Catherine McNeal Jones, MBA, HCM, RN BC USN Family Practice Clinic Diane Kelly, DrPH, MBA, RN Duke University Cooperatives Lisa Kristosik, RN, MSN VNA of Cleveland Cheryl Lovlien, MS, RN-BC Mayo Clinic Rosemarie Marmion, MSN, RN-BC, NE-BC AAACN Nancy May, RN-BC, BSN, MSN Scott White Health Sylvia McKenzie, MSN, RN, CPHQ University of Washington Kathy Mertens, RN, MN, MPH Harborview Medical Center Shirley Morrison, PhD, RN, OCN Texas Women s University Janet Moye, PhD, RN, NEA-BC George Washington Univ. Center for HC Quality Donna Parker, MA, BSN, RN-BC James H. Quillen VA Medical Center Carol Rutenberg, RN-BC, C-TNP, MNSc Deborah Smith, DNP, RN Georgia Health Sciences University Debra Toney, PhD, RN, FAAN Federally Qualified Health Center Barbara Trehearne, PhD, RN Group Health Linda Walton, MSN, RN, CRNP Orlando Health Physician Group Stephanie Witwer, PhD, RN, NEA-BC Mayo Clinic Wagner Model Reprinted with permission from the American College of Physicians. Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice. 1998; 1:2-4. Table 3. Cross Walk of Dimensions for Care Coordination and Transition Management with Core Competencies Dimension RN Care Coordinator and Transition Manager (RN- CCTM) Support Self-Management Quality and Safety Education for Nurses (QSEN) Core Competencies Patient-centered Care Public Health Nursing Competencies Interprofessional Education es/achne/files/quadcouncilcompe Collaborative Core Competencies tenciesforpublichealthnurses_sum mer2011.pdf ion-resources/ipecreport.pdf Education & Engagement Patient-centered Care of Patient & Family Cross Setting Patient-centered Care Interprofessional Communication Domain #3: Communication Skills Communication and Transition Coaching and Counseling of Patients and Families Patient-centered Care Domain #4: Cultural Competency Skills Nursing Process: Assessment, Plan, Evidence-based Practice Quality Improvement Roles and Responsibilities Domain #1: Analytic Assessment Skills Intervention, Evaluation Teamwork and Collaboration Teamwork and Collaboration Teams and Teamwork Domain #8: Leadership and System Thinking Skills Patient-Centered Planning Patient-centered Care Values/Ethics for Interprofessional Practice Domain #1: Analytic Assessment Skills Population Health Management Quality Improvement Informatics Domain #5: Community Dimensions of Practice Skills Domain #6: Basic Public Health Sciences Skills Advocacy Patient-centered Care Safety Domain #2: Policy Development/Program Planning Skills QSEN Competencies enc Are a Direct Match with RN N-CCTM Dimensions Patient Centered Care Quality Safety Teamwork Evidence-based Practice Informatics

6 Affordable Care Act (ACA) 2010 calls for coordination of care and management of transitions in all sites of care. Nurses are most likely to provide CCTM in many settings. However, CCTM is within the scope of practice of other professionals. Complex chronically ill individuals routinely move between care settings even on a daily basis. Affordable Care Act Fosters: Care Coordination and Transition Management Patient-centered Care that is grounded in best EBP, but tailored to patient goals, values and preferences Teamwork, with an emphasis on Interprofessional Collaboration and Teamwork Emphasis on high quality, safe care Tracking of processes and outcomes via documentation in EHR using informatics techniques Logic Models Use of Logic Model Have been used in Program Evaluation and Econometric Modeling to: 1. Delineate vision/purpose for a project 2. Surface assumptions, environmental issues and needed knowledge, skills and attitudes 3. Specify relationships among program goals, objectives, activities, outputs, and outcomes. 4. Clearly indicate the theoretical connections among program components; activities involved, who carries out the activities and specification of short, medium and long term outcomes. 5. Set up evaluation by assisting with development of the measures used to determine if activities were carried out (process and output measures) and if the program's objectives are met (outcome measures). retrieved 8/11/2013. Vision for the RN Care Coordination & Transition Management Model Provide structure and content for: 1. Education of RNs to work within the CCTM role 2. Employer position descriptions 3. Employer performance evaluation that uses QSEN KSAs specified in the RN-CCTM dimensions 4. Outcome measurement of impact of CCTM dimensions within and across organizations RN-CCTM CTM needed not only in ambulatory care RN-CCTM Logic Model Assumptions ns: CCTM Logic Model guided development of Patients will use primary care settings Patients will access RN-CCTM providers Patients will be engaged in care processes Providers will collaborate, work in teams, develop and use patient centered care plans Organization will have EHR that operates across settings Outcomes are often not discipline specific, but shared by team

7 Assumptions ACA fosters use of care coordination and evidence-based practice CCTM is needed by patients with complex chronic illnesses Risk stratification needed to identify patients who will benefit most from CCTM Risk stratification must use social determinants as predictors of risk level RN s can do CCTM in ambulatory care, acute care, home health care, rehabilitation etc. RN-CCTM Logic Model External Factors: Slow development of interdisciplinary team education and practice Changes in reimbursement and penalties for Never Events Decreasing revenue Slow implementation of EMRs that are operable across settings Slow development of model for care plan that moves between settings. Value Proposition for RN-CCTM Definitions: Value is an outcome of nursing practice (Edelbauer, Vlasses, & Rogers, 2013) Value = Outcomes Achieved Per Dollar Spent (Porter, 2010) Proposed Method of Developing el an Estimate of Value for RN N-CCTM If summative indicators are developed for these last three columns and they are imbedded in RN-CCTM documentation, as well as, documentation of other members of the interprofessional team And these indicators are coded in standardized language in an EHR, then: The documentation data sets can be queried Processes and outcomes can be mined from electronic documentation There will be real-time demonstration of processes done, outcomes achieved and value gained

8 Value Proposition for RN N-CCTM Proposed method of developing an estimate of value for RN-CCTM: Using the RN-CCTM Logic Model, The first column on the left specifies the dimension Second column specifies activities/interventions included in the dimension This column specifies who does the activities While the last three columns to the right specify short, medium and long term outcomes Short term outcomes can also been considered processes as can medium term outcomes Challenges: Areas Where KSAs Need to bede Developed and Implemented Developing and using Position descriptions that incorporate CCTM Competencies Developing education and evaluation methods that foster CCTM Competencies involving QSEN KSAs within and across professions Developing staffing models to support/resource the interprofessional team Building human resources/team configuration to support CCTM Creating an environment (physical and cultural) to support CCTM Developing/standardizing communication methods for communication across settings and between interprofessional team members Developing, testing and using process and outcome indicators to track the impact and value of RN-CCTM Standardization of Communication during Transitions of Care BOOST Better Outcomes by Optimizing Safe Transitions Introduction: Developed by: Society of Hospital Medicine Purpose: Assist in stratification of risk as well as assessment of needs Innovation/Mentored_Imple mentation/project_boost/about_boost.aspx Advantages to BOOST Goes beyond patient physical and psychological problems Goes beyond history of readmission and ED use Provides evidence-based predictors of risk that include social determinants Project BOOST Improving the hospital discharge care transition, Project BOOST aims to: Identify patients at high risk of rehospitalization and target specific interventions to mitigate potential adverse events Reduce 30 day readmission rates Improve patient satisfaction scores and H-CAHPS scores related to discharge Project BOOST (cont.) Improve flow of information between hospital and physicians and providers across the continuum Improve communication between providers and patients Optimize discharge processes and transitions Innovation/ Mentored_Implementation/Project_BOOST/About_BOOST.aspx What are social determinants of health? The social determinants of health are the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities - the unfair and avoidable differences in health status seen within and between countries.

9 Social Determinants In addition to the more material attributes of place, the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include: safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, environments free of life-threatening toxins. Exemplars Interprofessional-Collaborative Redesign and Evaluation for Population Access to Health (I-Care Path.) Vlasses, Hackbarth, Burkhart, Haas (Co-PD/consultant), Kouba and Michelfelder, Health Researches and Services Administration. NEPQR Grant # UD7HP26040 Education and training of PCMH staff on RN-Care Coordination and Transition Management Model, IPEC competencies and TeamSTEPPS Immersion training site for interprofessional students Use of the RN-CCTM Logic Model to guide development of process and outcome indicators for development of documentation screens in the EHR Use of BOOST to guide care interventions for complex diabetic populations and to standardize communication among interprofessional team members and across settings of care

10 Exemplars Ambulatory Care Translational Research, Quality Improvement Initiative: Application of the Project BOOST 8Ps Tool for Risk Identification and Stratification in Multidisciplinary Care Planning. Jessie, Anne. Capstone Project Methods: Stratification using NY State Heart Failure Classification, Modified LACE, BOOST for identification of care needs and stratification BOOST provides focus on social determinants (Health Literacy, support) and interventions, i.e., med rec and psychological issues EHR tracking of Health Literacy, Self Management, Medications Boost Gap Analysis Tool Electronic Health Record (EHR) Challenges 1. Patient Protection and Affordable Care Act mandates use of: Evidence-based accepted guidelines, but implementation is slow and there is a great lag time in: Getting evidence-based protocols into the EHR Development of documentation screens in EHR Development of process and outcome indicators for use in EHR documentation Development of Decision Support in EHR Use of EHR interprofessional documentation methods References Edelbauer, A., Vlasses, F., & Rogers, J. (2013). The Value Proposition in Nursing. Presentation at the International Nursing Administration Research Conference, Baltimore, MD. Haas, S., Swan, B.A., & Haynes, T. (Eds.) (2014). Care Coordination and Transition Management Core Curriculum. Pitman, NJ: Anthony J. Jannetti. Haas, S. & Swan, B.A. (2014). Developing the Value Proposition for Registered Nurse Care Coordination and Transition Management Role in Ambulatory Care Settings. Nursing Economic$, 32(2), Haas, S. & Swan, B.A. (2014). Emerging care coordination models for achieving quality and safety outcomes for patients and families. In Lamb, G. (Ed.), Care Coordination the Game Changer. Washington, DC: American Nurses Association. Haas, S., Swan, B. A. & Haynes, T. (2013). Developing ambulatory care registered nurse competencies for care coordination and transition management. Nursing Economic$, 30(1), 44-49, 43. References (cont d) Haas, S., Hackbarth, D., Kavanagh, J., & Vlasses, F. (1995). Dimensions of the staff nurse role in ambulatory care: Part II Comparison of role dimension in four ambulatory settings. Nursing Economics, 13(3), McDonald et al., 2007 in AHRQ Care Coordination Measures Atlas, 2010, p Naylor, M. & Sochalski, J. (2010). Commonwealth Fund Issue Brief - Scaling Up: Bringing the Transitional Care Model into the Mainstream. retrieved 3/19/15 Up-Transitional-Care.aspx Porter, M. J. (2010). What is value in health care? New England Journal of Medicine, 363, Swan, B. A., Haas, S. A., and Chow, M. (2010, October). Ambulatory care registered nurse performance measurement. (AHRQ grant HS18885). Nursing Economics, 28(5), pp