Running head: COMMUNITY PROJECT 1. Community Project: Nurse Educator for Heart Failure Patients

Running head: COMMUNITY PROJECT 1 Community Project: Nurse Educator for Heart Failure Patients Isaac Agbettor, Anise Camacho, Nicole Hassna, Yesenia Hurtado, and Matthew Vega October 11, 2013 NURS 4410: Community Health Nursing Practicum

COMMUNITY PROJECT 2 Community Project: Nurse Educator for Heart Failure Patients A large portion of patients in Stockton, California and surrounding areas receiving care from St. Joseph s Medical Center Home Health Care (SJMCHHC) suffer from heart failure (HF). Although SJMCHHC nurses teach patients with HF ways to manage their sodium intake, promote physical activity, and manage their medication regimen, there is a disconnect between the knowledge taught to patients and the perceived understanding and self-care changes from the patients with HF. Many nurses of SJMCHHC have expressed not having adequate time to teach patients with HF thoroughly due to time constraints for care from health insurance companies. These time limitations do not allow the home health nurses to assess adequately the learning styles, knowledge, and understanding of their patients, creating gaps in HF teaching and self-care changes. The benefits of having a nurse educator to assess HF patients learning styles to tailor care plans could effectively assist a patient to understand the importance of keeping up with the medications, lowering sodium intake, and having more physical activities in their lifestyles. The purpose of this project is to identify the problem of HF teaching in the community and the disconnect between knowledge and understanding; and to propose a program that institutes a nurse educator to perform learning assessments at the start of SJMCHHC case openings and cater care plans to these specific HF patients for nurses to implement for their teachings. Assessment and Problem Identification The health problem chosen for this project is HF. According to the Center for Disease Control and Prevention (CDC), HF happens when the heart cannot pump enough blood and oxygen to support the organs (Center for Disease Control and Prevention [CDC], 2013). Around 5.7 million people in the United States have HF and it costs the nation $34 billion each year (CDC, 2013). About half the people who have HF die within five years of diagnosis (CDC,

COMMUNITY PROJECT 3 2013). Many risk factors contribute to HF. Among the top risk factors are coronary artery disease (CAD) and advancing age (Lewis, Dirksen, Heitkemper, Bucher, & Camera, 2011). Other contributors such as hypertension, diabetes, cigarette smoking, obesity, and high cholesterol contribute to the development of HF (Lewis et al., 2011). These factors are controllable and can be prevented with changes in diet, activity, and lifestyle. According to the United States Department of Health and Human Services (HHS), approximately 1 in 3 adults in the United States and more than half of Americans with high blood pressure do not have it under control (United States Department of Health and Human Services [HHS], Healthy People 2020, 2013). In addition to high blood pressure, sodium intake is not controlled, where about 90 percent of American adults exceed the recommended daily sodium intake (HHS, Healthy People 2020, 2013). HF education encompasses different aspects of a patient s lifestyle that needs remediation such as diet, exercise, medication, and signs and symptoms. For an average patient, teaching of all of this information can be overwhelming. Nurses can intervene by providing tailored education to a patient s learning needs to deliver the health information effectively and more likely promote self-care changes. Involved Participants The implementation of the nurse educator project and the inclusion of patients with HF into the project is supported by the statement that [HF] is the most common reason for hospital admission in adults older than 65 years and consequently places a significant economic burden on the health care system (Lewis, Dirksen, Heitkemper, Bucher, & Camera, p. 797, 2011). Due to the high number of patients who suffer from HF in the Stockton area and are consequently hospitalized, the participants in our group s teaching project will include patients diagnosed with HF from the Stockton area that use SJMCHHC as well as a nurse educator whose role will be to

COMMUNITY PROJECT 4 provide one-to-one teaching assessment to discharged HF patients. The nurse educator will possess at least a master s degree and will assess the patient once a referral is made for the patient to begin receiving services through SJMCHHC. The nurse educator s assessment will help tailor care plans specific to the patient s needs that the home health nurse can then follow and implement to provide HF care and teaching to the patient with HF. According to a study by Manning (2011), two Randomized Controlled Trials (RCTs) were performed and the researcher found a great decrease in the number of re-hospitalizations of HF patients after an intensive, 60- minute, 1-on-1 teaching session with a [HF] nurse educator either at the time of or within 2 weeks of discharge and both trials also reported an overall cost savings between $2,823 and $7,515 per patient. The participants would include patients discharged to SJMCHHC with HF. Public Policy that Impacts Project President Obama signed the Patient Protection and Affordable Care Act (P.L. 111-148) in 2010 (Kaiser Family Foundation, 2013). According to the Patient Protection and Affordable Care Act, the National Prevention, Health Promotion, and Public Health Council was to be established and the council was to develop a strategy to coordinate federal prevention, wellness, and public health activities to improve the nation s health (Kaiser Family Foundation, 2013, p. 10). The National Prevention Strategy was released in July 2013, and specifically outlined the recommendations for Clinical and Community Preventative Services (HHS, 2013). Some of the suggestions in the National Prevention Strategy include [supporting] the National Quality Strategy s focus on improving cardiovascular health and [informing] patients about the benefits of preventative services and [offering] recommended clinical preventive service (HHS, 2013). However, the most influential of the recommendations and the one that makes an impact on the objective of implementing a nurse educator in home health is to communicate with

COMMUNITY PROJECT 5 patients in an appropriate manner so that patients can understand and act on their advice and directions (HHS, 2013). This recommendation suggests that preventive services within in the community be geared to ensuring that patients have a complete understanding of their health and teachings, so much that they are able to implement these self-care changes into their lives. By having this public policy in place, it makes it a requirement for the American community health force to gear its practices towards these suggestions and the opportunity for the nurse educator to enact these recommendations clinically. The nurse educator program for SJMCHHC for patients with HF could be influential to the community and to future public policy reform in being able to provide proof of these attainable suggestions. In addition, the program could provide possible further improvements to policy by incorporating specific examples of implementation of ways to communicate to patients in such a way that fosters understanding, knowledge, and self-care change. Project Planning The purpose of this project is to decrease the number of patients being readmitted to hospitals for HF ultimately. The nurse educator will provide a one-to-one assessment to patients diagnosed with HF, and based on that assessment, the educator will develop teaching materials unique to that patient s needs and learning method. The goal of the project is to assess patients diagnosed with HF during admission or within two weeks after discharge from the hospital to SJMCHHC. A home health nurse holding a master s degree will be conducting the assessment and education planning. Half of the patients hospitalized with HF complications are readmitted within six months (Stromberg, 2005). Many of these cases are due to the failure of healthcare providers to target high-risk patients, prescribe optimal treatment, discharge planning, education,

COMMUNITY PROJECT 6 and follow up (Stromberg, 2005). The nurse educator program will target all HF patients opened to SJMCHHC to help decrease their chances of being readmitted. Possible anticipated special considerations include language barriers, low levels of knowledge on HF, older patients with low education levels, low motivations to learn, and functional and cognitive impairments. These barriers will be accounted for by having an interpreter, when needed, during the interview, and teaching with the nurse educator from home health. Material will also be provided in the patient s native language to increase knowledge. Stromberg (2005, p. 363) states that knowledge increases perceived control and facilitates the patient s adaptation to the chronic-illness role and self-care behaviour, making it vital to instill a nurse educator to furnish knowledge for patient adaptation. Other barriers will be addressed by the patient and the nurse educator working together to develop a plan of education that will fit the client needs. Implementation of this project will require a nurse educator along with printed materials. An estimated budget has been proposed for this budget. The budget includes the estimated amount for printed material and the annual salary for the nurse educator (see Table 1.1). One way of funding this program will be to be connected with the state universities in the area, such as California State University Sacramento or California State University Stanislaus, and have the project be an externship option for their master s degree program in nursing. A pilot program will be in place for the first two years to evaluate the effectiveness of this program with SJMCHHC and obtain further funding accordingly. Another option for funding would be to work with Medicare and have Medicare help fund this project since it may be incentive for cutting cost in future hospitalizations of patients with HF by reducing re-hospitalizations. The goal of Medicare is to decrease hospitalizations from cardiovascular problems; this preventative

COMMUNITY PROJECT 7 project will help to achieve this goal. Over time, with success of the proposed project, more nurse educators will be needed as well as different educational resources that become available. These options will be indicative of the progress and outcomes of the pilot project. Implementation In order to implement the project effectively, there is a need for nurses specialized in patient education as well as current evidence based practice (EBP) pertaining to HF. These nurse educators will focus on health literacy and its impact on teaching critical skills effectively and efficiently and knowing the Six Required Elements of Discharge instructions for HF patients (Rosemary, 2012). The education for patients with HF will deal with tertiary prevention focusing on preventing further damage, slowing the disease, minimizing complications, and providing a better quality of life for patients with HF. In order to effectively implement these teachings, the nurse educator must take into account health literacy, which Healthy People 2020 defines as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions (HHS, Healthy People 2020, 2013). In the community, either many individuals lack the ability to read, or they can read but have difficulty understanding what they read. According to the National Assessment of Adult Literacy (NAAL), almost half of all adults in the US have poor to marginal literacy skills and this number runs higher in areas of low income and high immigrant populations (National Center for Education Statistics [NCES], 2010). In order to overcome these barriers in learning, the nurse educator must be able to assess what each patient needs to know in comparison to what the patient already understands about his or her condition and what he or she is willing to do to care for their HF. The nurse educator must also be able to incorporate care plans that teach the patient when and why he or she must notify the nurse or provider. The

COMMUNITY PROJECT 8 educator can accomplish this by focusing on these basic ideas to include in individualized care plans for patients with HF for cases opening with SJMCHHC: Slow down in order to give patient time to process information. Use non-medical language to enhance literacy. Draw pictures because many patients are visual learners. Limit the amount of information. People reach a maximum amount of learning and cannot process anymore. For this reason, do not use more than three handouts. Encourage questions. This will help clarify any breaks in understandings as well as reinforce important information. Ask patients to explain their understanding of their medical problem or treatment. Many patients do not understand their disease or treatment. By asking them to explain their disease or treatment, nurses create a great opportunity to assess the patient s level of understanding of their condition and the nurse can teach based on this level as a baseline. Use Teach-back. Teach-back lets the nurse know that they have explained what the patient needs to know in a way the patient understands. This can be accomplished by asking patients to demonstrate the skills the nurse has taught them following the teaching. The last portion of the education in care plans will focus on teaching the Six Required Elements of Discharge (Rosemary, 2012), which both the nurse and patient must know in order to maximize recovery and quality of life. The Six Required Elements of Discharge as proposed by Rosemary (2012) include: 1. Weight monitoring 2. What to do if symptoms worsen 3. Diet

COMMUNITY PROJECT 9 4. Discharge medications 5. Follow-up appointments 6. Activity level By including these six elements, the nurse educator will incorporate many factors that affect a patient s HF, and by using the previous seven basic principles, the nurse will make sure that the patient understands what he or she must do to maximize their self-care of HF. While it would be most advantageous to be able to have a specialist HF educator, it may not always be a possibility due to lack of funds or resources. An alternative approach would be an interactive educational class for home health nurses that focuses on the seven basic principles highlighted previously. With the education, the home health nurses will have the knowledge and tools to more effectively educate their patients on HF management and care. Evaluation A method of determining the effectiveness of the use of a nurse educator involves tracking the patients who received health education provided by the nurse educator. Following up with the patients to assess the effectiveness of the teaching will also require monitoring the number of re-hospitalizations of those patients and documenting how frequently or infrequently the patients were readmitted for the same conditions for which they originally received teaching by the nurse educator. Per Healthy People 2020 objectives, it would be beneficial to achieve a 10% decrease in the number of re-hospitalization of the included patients for HF (HHS, Healthy People 2020, 2013). Additionally, health statuses of each of the patient s in the population from their medical doctors on his or her conditions could be compared from the start of the program to the evaluation point. This could include diagnostic values, as well as the doctor s impression from the start and evaluation phases of the project for the patient s condition as it pertains to the

COMMUNITY PROJECT 10 patient s HF. The understanding and knowledge of the teachings to the included patients with HF could also be evaluated by follow-up from SJMCHHC nurses to assess the patients incorporation of the self-care changes necessary to maintain their HF. This could be concluded with personal evaluations from nurses with the patients, patient testimonies of health and understanding, or using evaluative tools such as satisfaction scales to understand the patient s perception of their self-care abilities and understanding of teachings for the autonomy with maintaining their HF. Research Review Related to Selected Population In a study by Dickson, Riegel, and Lee (2011), the researchers used qualitative and quantitative research methods to investigate how the self-care of a patient with HF is affected by cognitive function and knowledge. The authors also used the study to explore how varied methodologies can alter the understanding of the clinical aspects of HF (Dickson, Riegel, & Lee, 2011). The use of mixed methods showed that deficient understanding resulted in poor self-care practices, not deficient knowledge of the clinical disease practices of HF (Dickson, Riegel, & Lee, 2011). Cognitive impairments were influential on self-care behaviors for HF as well (Dickson, Riegel, & Lee, 2011). Overall, the research suggests that the disconnect between knowledge and understanding for patients with poor self-care behaviors for maintaining HF are attributed to cognitive impairments and inadequate education (Dickson, Riegel, & Lee, 2011). The research suggests that education to patients with HF needs to be aimed at teaching for constructing understanding and necessary skills for self-care, as opposed to reiterated knowledge; assessing patients perceptions of knowledge and practices toward HF self-care; and individualizing teaching to broaden patient understanding (Dickson, Riegel, & Lee, 2011).

COMMUNITY PROJECT 11 These goals support the overall objective for a nurse educator for assessing patients with HF in home health care. Kommuri, Johnson, and Koelling (2011) conducted a study at the University of Michigan that examined the changes in performance on HF knowledge assessments administered before and after discharge education. Study subjects were recruited from eligible candidates admitted to the hospital with a diagnosis of HF, specifically left ventricular systolic dysfunction (Kommuri, Johnson, & Koelling, 2011). There were 265 patients randomized to receive usual care (standard discharge information) or usual care and a one-hour long nurse educator- delivered HF education program (Kommuri, Johnson, & Koelling, 2011). The education session provided to the intervention group covered details about the basic principles of HF and basic care information and both groups (the control group and the intervention group) were given a HF knowledge questionnaire (Kommuri, Johnson, & Koelling, 2011). The questionnaire was administered to the study population at baseline and three months after hospital discharge by the study coordinator (Kommuri, Johnson, & Koelling, 2011). Patients randomized to the nurse education intervention demonstrated significantly higher total questionnaire score increases compared to patients receiving the standard discharge process (Kommuri, Johnson, & Koelling, 2011). According to the article, one hour long [HF] nurse education at the time of hospital discharge resulted in improved patient knowledge and reduced risk of readmission (Kommuri, Johnson, & Koelling, 2011, p. 237). In order to reduce hospital readmission in patients with HF, the study by Kommuri, Johnson, & Koelling (2011), in addition to others, suggests and recommends the use of a nurse educator either at the time of discharge or after discharge from the hospital to assess patients and provide teaching based on their assessment.

COMMUNITY PROJECT 12 Education plays a vital role in a person s health maintenance. Research has shown that there is an inconsistency on the perception on the learning needs of HF patients (Boyde et al., 2009). Focusing on the patient individual needs or preferred learning style can be more effective. According to Boyde et al. (2009), identifying a patient s learning style can contribute to development of learner specific education resources for HF patients. This study used a qualitative design that evaluated a small population s learning styles in order to identify the patient s learning needs (Boyde et al., 2009). Participants were interviewed and asked to complete a questionnaire about their learning style (Boyde et al., 2009). From their data, the researchers identified whether the participants were visual, auditory, read/write, kinesthetic, or multimodal learners; along with common themes that emerged among the participants (Boyde et al., 2009). The L-loading participants learned by life experiences; they preferred poster information, and brochures (Boyde et al., 2009). They remembered information from the hospital; their learning style was described as hands-on and by experimentation (Boyde et al., 2009). The L- inhibitors are learners that had different variable that blocks their learning of the condition (Boyde et al., 2009). For instance, the people delivering the information, conflicting information, and non-disclosed information all affected the learning of the participant. L-agonists are active learners that are motivated and seek out relationships with healthcare professionals about their condition (Boyde et al., 2009). Researchers found that learning in groups provided reinforcement for these types of learners (Boyde et al., 2009). The last category was L-titration learners, which were learners that benefited from text and talk from healthcare professionals (Boyde et al., 2009). The research suggests that identifying delivery preferences of HF patients provide practical suggestions about how educational information can be packaged to meet these learning preferences (Boyde et al., 2009).

COMMUNITY PROJECT 13 Frequent readmission of patients with HF causes a burden on their bodies, the family, and the healthcare system (Stromberg, 2005). A literature review to understand the causes of readmission to the hospital of patients with HF was conducted by A. Stromberg (2005). Stromberg (2005) shows that different variables play a role in a patient s risk of being readmitted to the hospital. The variables include the level of knowledge in patients with HF, barriers to learning, learning needs, and educational methods (Stromberg, 2005). A big part of preventing readmission would be to target high-risk patients. This will allow the health care provider to educate the patient accordingly and prevent further readmissions. Stromberg (2005) found that many patients did not understand what HF is. To be able to educate these patients it is necessary to assess their learning style and target any learning barriers. Educational interventions need to, specifically to elderly patients, address any misconceptions, low motivation, and self-esteem (Stromberg, 2005). This research found that education is an important component of HF care and should be delivered effectively to ensure patient understanding (Stromberg, 2005). Strength of this research is the exploration of different aspects of learning as well as barriers to learning. These variables have a significant effect in the level of knowledge of HF in a patient, which affects how the patient takes care of himself or herself. A weakness is that the research was focused on the elderly patients mostly 65 years and older. A better understanding of readmissions could be gathered if the population was expanded to include other age ranges. AHC Media (2011) published a journal article detailing the effectiveness of teach-back with heart failure patients. Their studies showed that in hospitals that implemented teach back protocols in their education programs for patients with heart failure, there was a 12%-33% reduction in readmissions (AHC Media, 2011). This success was attributed to the opportunities that arise with teach-back education, which included the ability to swiftly assess the patient s

COMMUNITY PROJECT 14 level of understanding, to identify gaps in knowledge and rephrase those messages, and to have the patient demonstrate their understanding in their own words (AHC Media, 2011). In conclusion, the nurse educator would assess a patient s learning style, knowledge, and understanding with regards to HF for new patients to SJMCHHC in the Stockton, California area. Based on the patient s knowledge, learning style, and understanding, the nurse educator would coordinate with home health nurses to provide teaching on medication compliance, lowering of sodium intake, and increasing patient s physical activities in order to reduce HF readmission. The nurse educator would provide an initial assessment of learning styles and incorporating findings into care plans for home health nurses. These care plans and assessments would include the ideas that would make teaching and care the most individualized as possible and cater to the patient s knowledge and learning. The project could be incorporated into the local universities as externships for master s degree nursing students and the first two years of the project could serve as a pilot for the entire project to gauge success. Last, the project would be evaluated using re-hospitalization statistics for the included patients, nurses and doctors assessments, and patients satisfaction and understanding. Overall, the project could prove to be a successful example of the public health policies that are being enacted with the Patient Protection and Affordable Care Act. Great lengths and dedication would be necessary to ensure that the nurse educators were themselves fully educated on the aspects of learning assessments, using a holistic approach to assessment to nursing, and great skills in planning care; however, if so, the project could be proven to be successful and beneficial to patients with HF.

COMMUNITY PROJECT 15 References AHC Media (2011). To reduce heart failure readmissions use the teach-back method. Patient Education Management, 18(10), 109-111. Boyde, M., Tuckett, A., Peters, R., Thompson, D., Turner, C., & Stewart, S. (2009). Learning for heart failure patients (the L-HF patient study). Journal of Clinical Nursing, 18(14), 2030-2039. doi:10.1111/j.1365-2702.2008.02716.x Center for Disease Control Prevention. (2013) Heart Failure Fact Sheet. Retrieved from http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm Dickson, V. V., Riegel, B., & Lee, C. S. (2011). How do cognitive function and knowledge affect heart failure self-care?. Journal of Mixed Methods Research, 5(2), 167-189. doi: 10.1177/1558689811402355 Kaiser Family Foundation (2013). Summary of the Affordable Care Act. Retrieved from http://kaiserfamilyfoundation.files.wordpress.com/2011/04/8061-021.pdf Kommuri, N. V., Johnson, M. L., & Koelling, T. M. (2011). Relationship between improvements in heart failure patient disease specific knowledge and clinical events as part of a randomized control trial. Patient Education and Counseling, 86(2), 233-238. doi: 10.1016/j.pec.2011.05.019 Lewis, L. S., Dirksen, R. S., Heitkemper, M. M., Bucher, L., & Camera, M. I. (2011). Medical- Surgical nursing: Assessment and management of clinical problems. St. Louis, MO: Mosby Manning, S. (2011). Bridging the gap between hospital and home: A new model of care for reducing readmission rates in chronic heart failure. The Journal of Cardiovascular Nursing, 26(5), 368-376. DOI: 10.1097/JCN.0b013e318202b15c

COMMUNITY PROJECT 16 National Center for Education Statistics. (2010). Adult literacy. Retrieved from http://nces.ed.gov/fastfacts/display.asp?id=69 Retrieved from http://www.queri.research.va.gov/chf/products/nurse_education/healthliteracy- And-TeachBack.pdf Rosemary, M. (2012). Health literacy and teach back. CHF Queri: Heart Failure Nurse Education Strömberg, A. (2005). The crucial role of patient education in heart failure. European Journal of Heart Failure, 7(3), 363. United States Department of Health and Human Services (2013). Clinical and community preventative services. Retrieved from http://www.surgeongeneral.gov/initiatives/prevention/strategy/clinical-and-communitypreventive-services.html# United States Department of Health and Human Services, Healthy People 2020.(2013) Heart disease and stroke. Retrieved from http://www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=21

COMMUNITY PROJECT 17 Table 1.1 Estimated Budget Amount Annual salary for nurse educator $90,000- $120,000 Printed material $2000 Miscellaneous $2000 Total Annually $130,000-160,000