Transcript Mr. Smith, a 76 year old male admitted to an acute care hospital for

The Role of the CNS in Transitioning
the Frail Elderly
Ellen McPartland, MSN, CNS, CRNP
Pennsylvania Hospital
University of Pennsylvania Health System
Octobers 26, 2012
Presentation Objectives
• Provide a common health care scenario of a high risk frail
elderly patient transitioning from hospital to home
• Describe the key concepts supporting the Transitional
Care Model
• Discuss the core competencies of the CNS
• Summarize key findings from testing of the TCM led by
an APN/CNS
• Describe the impact of the body of evidence from testing
the TCM from clinical practice and future healthcare
initiatives
A common scenario from hospital
discharge to home
Mr. Smith, a 76 year old male admitted to an acute
care hospital for exacerbation of CHF.
• PMH includes HTN, Hyperlipidemia, A-fib, CAD,
COPD, DM, hypothyroidism, and prior ischemic
stroke
• Nine daily medications
• Patient follows up with an internist and 2
specialists for his multiple health conditions
• Second hospitalization in 3 months
Scheduled for Discharge to Home after
2-Day Length of Stay
• Discharge instructions include 3 medication changes
and a sodium restricted diet.
• His 76 year old wife has a similar profile of chronic
health problems and is too frail to visit him in the
hospital, so he takes a cab home.
• Both have undiagnosed cognitive impairment and have
lost some executive function.
• They have no children, but receive help from neighbors.
How will they manage the
transition back to their usual
state of health given the support
provided by “usual care?”
If they are fortunate…
• Their internist will receive timely communication from
the hospital re: Mr. Smith’s illness and treatment
received.
• He will be seen in the office soon after discharge to
detect and manage residual health problems.
• The local pharmacist will know Mr. Smith and will
reconcile his previous and new medications and may
even consider the couple’s cognitive function in the
dispensing plan.
• The discharge planner may have consulted a home care
nurse who will visit within a few days. The neighbors
may check on them.
On the Other Hand…
Maybe the Smiths will fall
through the enormous cracks
in our current health care
system and none of these
supports will take place...
…Or maybe they will
receive care from a APN
such as the Clinical
Nurse Specialist.
Patient Factors Contributing to
Poor Outcomes
•
•
•
•
•
•
•
Multiple chronic conditions
Functional deficits
Cognitive Impairment
Lack of support
Poor general health behaviors
Language and cultural barriers
Problems with health literacy
Poor Outcomes: System Factors
• Multiple providers
• Inconsistent medical management
• Poor communication
• Poor Health literacy
• Limited access to services (reimbursement)
• Narrow perceived accountability
• Lack of systems to bridge transitions
At Risk Population Such
as the Frail Elderly
• Frailty is a multi-dimensional cluster of common factors
that contribute to diminish independence in activities of
daily living.
• It is most prevalent among the old, especially those who
are 75 years of age or more.
• The clusters can include physical dysfunction,
cognitive/psychological impairments, and or socialeconomic and nutrition problems.
(Levers, Estabrooks, & Kerr, 2006).
The Case for Transitional Care
• Huge gaps in care
• Serious unmet needs
• Poor care experiences, esp. for cognitively
impaired older adults + family caregivers
• High rates of medical errors
• High rates of preventable readmissions
• Tremendous human & cost burden
Transitional Care
• 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.
• Designed to bridge gaps that occur as a result of having
multiple players involved in care or to bridge the gaps that
occur when a patient moves from one site of care to
another.
The Importance of the APN-led
Transition from Hospital to Home
• A time when miscommunication and
misinformation can occur.
• A time when much patient/family
educating, coaching and guidance is
needed.
• A time when having the knowledge and
skills to navigate a complicated health care
system is needed.
• A time when collaboration and
coordination of care is needed to prevent
an avoidable rehospitalization.
Core Competencies of the CNS
• A clinical expert
• Educating, coaching, and guidance adaptable to
patient/family or groups
• Clinical professional and leadership skills
• Skilled in ethical decision making
• Collaboration
• Consultation
• Research
Three Spheres of Influences
Evolution of the
Transitional Care Model
• Developed in 1980 as a response to shortened hospital
lengths of stay.
• Pressure to provide effective health care services at
lowest cost.
• Initially tested with early discharge of low birth weight
infants.
• Recently the model has been applied to improve
outcomes and reduce cost of care for hospitalized elders.
Mary D. Naylor, Ph.D., R.N., FAAN
Marian S. Ware Professor in Gerontology
Director, New Courtland Center for Transitions and Health
Since 1989, Dr. Naylor has led an
interdisciplinary program of research
designed to improve outcomes and
reduce costs of care for vulnerable
community-based elders.
Her work is focused on discharge
planning and home follow-up of
high-risk elders by advanced practice
nurses.
Through her research, Dr. Naylor has
added to what is known about
advanced practice nursing and
transitional care.
Transitional Care Model
Key Components
• Focus on Patient and Caregiver Understanding
• Helping Patients Manage Health Issues and Prevent
Decline
• Medication Reconciliation and Management
• Transitional Care, Not Ongoing Case Management
Transitional Care Model - APNC
Care is delivered and
coordinated
…by same advanced practice nurse
…across settings
…7 days per week
…using evidence-based protocol
…with focus on long term outcomes
National Average Readmission Rate at 52w: 56.1%
1
Naylor et al. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006.
Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281:613620.
3 Naylor et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675684.
2
at 26
weeks**
at 52
weeks***
TCM's Impact on Total Health Care Costs +
$7,636
$12,481
TCM
Group
Control
Group
$3,630
$6,661
Dollars (US)
+
Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits,
and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention
group total.
** Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial.
JAMA. 1999;281:613-620.
*** Naylor et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am
Geriatr Soc. 2004;52:675-684.
Enhancing Transitional Care
for Cognitively Impaired Older Adults
and Their Family Caregivers (ECC)
Study Sites
Study Aim
Test care innovations among hospitalized
cognitively impaired older adults, designed to:
•
•
•
•
•
Improve the care experience
Enhance function & quality of life
Minimize caregiver burden
Prevent avoidable rehospitalizations
Decrease health care costs
Patient Demographics
• Age: 80.7 ± 7.7 (65-102) years
• Female: 67.5%
• African American: 59.4%
• Education: 11.7±3.4 (2-25) years
Patients’ Clinical Characteristics
Percentages may
not add to 100%
due to rounding.
Median number of co-morbidities, 5 (range: 0-13)
Median number of medications, 8 (range: 0-27)
Rates and Types of Patients’
Cognitive Deficits
•
•
•
•
54.2% deficits in orientation/recall
16.2% diagnosis of dementia
24.7% delirium (+ Confusion Assessment Method)
MMSE: 21.9 ± 5.4 (2-30) [n=268]
Caregiver Demographics
•
•
•
•
•
Age: 58.6±13.9 (18-93) years
Female: 74.2%
African American: 58.3%
Education: 13.7±2.7 (5-26) years
Relationship to Patient:
Caregiver Burden
Although overall burden was low, higher CG
burden was highly associated with:
•
•
•
•
•
↓MMSE scores
Presence of delirium
Patient depressive symptoms
CG depressive symptoms
Patient having diagnosis of dementia
.
Clinical Information System
& Data Collection
• Developed a clinical information system with a relational
database to house our tools
• Chose the Omaha System for standardized
documentation as it helped to determine “what did the
nurses do?”
• Problem classification Scheme ( client assessment)
• Intervention Scheme ( care plans and services)
• Problem Rating Scale for outcomes( Client
change/evaluation)
Results
•
•
•
•
•
271 Patients-Caregiver dyads
Over a period of 1-3 months
Average 13.6 visits & 13.9 phone calls
Identified on average 4.5 problems per patient (range 1-11)
Conducted on average 158 interventions per patient
Readmission Rates by Group*
* Using Kaplan-Meier estimates, weighted by propensity scores
50.00%
45.00%
40.00%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
apnc
rnc/asc
nat avg+
0-30 days 0-60 days 0-90 days 0-180 days
+ Jenks
et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360:1418-1428
Results Patient Problems
• The complexity of care was evident with 71% of the 42 Omaha
System problems present in the sample.
• Most common problems were:
Urinary function
Bowel function
Communication with community resources
Respiration
Neuro-musculo-skeletal function
Medication regimen
Nutrition
Health care supervision
Circulation
Cognition
0
50
100
150
200
250
Signs and Symptoms
• Patients experienced 188 discrete signs and symptoms
• Average 11.5 (range 1-41)
• Most common symptoms managed by APNs were:
limited concentration
diminished judgment
abnormal blood pressure reading
edema
does not follow recommended dosage/schedule
nonadherence to prescribed diet
gait/ambulation disturbance
disoriented to time/place/person
limited reasoning/abstract thinking ability
limited calculating/sequencing skills
limited recall of recent events
0
50
100
150
200
250
300
Interventions
A total of 42,949 interventions were completed.
Using Qualitative
Methods to Describe APN Care*
• Theme #1: Having the Necessary Information and Knowledge
• Theme #2: Care Coordination
• Theme #3: Caregiver Experience
Bradway, C., et al. (2011)
Theme #1: Having the Necessary
Information and Knowledge
Barriers
Facilitators
• Low health literacy
• Lack of knowledge of
chronic illness
• Lack of
acknowledgement of
severity or implications
of illness
• Compounded by CI
• Rapid identification of
gaps in knowledge and
educational needs
• Innovative strategies to
get information to dyads
• Trusting relationship,
support via APN-directed
protocol, shared
understanding of goals
Theme #2: Care Coordination
Barriers
• Difficulty scheduling
appointments
• Missed appointments
• Refusal of services
Facilitators
• APN advanced skills and
collaboration with other
heath care providers
• Worked tirelessly to
achieve goals and
coordinate care
• Went “above and
beyond” typical care by
doing everything
necessary to identify and
ensure success
Theme #3: Caregiver Experience
Barriers
Facilitators
• Overwhelmed CGs
• Poor coordination among
multiple CGs
• APNs reach out by
multiple means and over
and over again as
needed
• Staying in close contact
• Helped dyads
understand and accept
chronic conditions
Study Conclusions/Discussion
• “What did the nurses do?”
• The ability to retrieve the APNs documentation showed the:
o Complexity of patients
o Most common problems experienced
o Large range of symptoms
o Vast amount of education we provide
• Critical challenges and facilitators to providing care can be
identified and used to plan care and policy
Translating to Clinical Practice
QI Priorities/Opportunities*
• Best practices for gathering, storing, and communicating
patient information
• Training to recognize “at risk” patients
• Technology for monitoring high-risk patients
• Addressing advance directives
• Coordinating follow-up care
* Golden, et al, 2010
The TCM: Summary/Conclusions
• A well-established model of care
o Evidence of effectiveness
o Significant APN role with focus on inter-professional team
• Translation of the TCM into practice
• Future research:
o Examination of the TCM with additional populations and in other
settings
 Nursing home to hospital transitions
 Specialty populations
Resources and References
• Bradway, C., et al. (2011) A qualitative analysis of an
advanced practice nurse-directed transitional care model
intervention. The Gerontologist. Doi: 10.
1093/geront/gnr078
• Jenks et al. Rehospitalizations among Patients in the
Medicare Fee-for-Service Program. New England Journal
of Medicine 2009; 360:1418-1428
• Levers, M.J.,et al.(2006). Factors Contributing to Frailty:
literature review. J Adv Nurs, 56 (3): 282-91
• Naylor, M., et al. (1999). Comprehensive discharge
planning and home follow-up of hospitalized elders: A
randomized controlled trial. JAMA, 281, 613-620.
Resources and References
• Naylor, M.D., et al. (2009). Translating research into
practice: Transitional care for older adults. Journal of
Evaluation in Clinical Practice, 15, 164-1170.
• Naylor, M. D., et al. (2007). Care coordination for
cognitively impaired older adults and their caregivers.
Home Health Care Services Quarterly, 26(4), 57-78.
• Naylor, M.D., et al. (2010). Enhancing care coordination
for cognitively impaired older adults and their family
caregivers. Gerontologist, 50(S1), 50. doi:
10.1093/geront/gnq115
• www.transitionalcare.info
• www.caretransitions.org