Diane E. Holland, PhD, RN Clinical Nurse Researcher and Associate Professor Mayo Clinic Rochester, MN, USA

Transcription

1 Diane E. Holland, PhD, RN Clinical Nurse Researcher and Associate Professor Mayo Clinic Rochester, MN, USA 3 rd Annual ICHNO Conference Chicago, IL, USA July 10, 2015

2 Mayo Clinic Rochester Mayo Clinic Scottsdale Mayo Health System Mayo Clinic Jacksonville CP

3 ACKNOWLEDGEMENTS Team Members Catherine E. Vanderboom, PhD, RN (Co-PI) Cory J. Ingram, MD, MS, FAAHPM Ann Marie Dose, PhD, RN Ellen Wild, RN, CHPN Jay Mandrekar, PhD Christine M. Austin, RN, CCRP Adriana Delgado, M Adm Kathryn Bowles, PhD, RN, FAAN, FACMI Funding Mayo Clinic CCaTS Small Grants Program

4 TECHNOLOGY-ENHANCED TRANSITIONAL PALLIATIVE CARE Strategy - link 3 evidence-based approaches: Palliative Care Transitional Care Technology

5 PALLIATIVE CARE Team approach for caring for the seriously ill patients and their families Early intervention decreases symptom burden and increases Quality of Life Limited transitional support to assist patients/ families eligible for palliative care from the hospital to community-based settings

6 TRANSITIONAL CARE MODEL Developed as an approach to provide continuing care from hospital to home One nurse follows the patient in the hospital and at home Consistently demonstrated improved quality, satisfaction with care, and reductions in hospital readmissions and healthcare costs

7 TECHNOLOGY Single most important way to equalize the differences in resource availability between rural and urban areas Existing technology widely used and liked by patients/families High patient and clinician satisfaction Visual capabilities provides cues for enhanced communication

8 THE GAPS Transitional Palliative Care is relatively new Transitional Care Model not yet tested where face-toface interactions by the same nurse across settings are physically impossible (transitioning from urban medical centers to rural homes) Virtual technology widely available but rarely used for nurse visits No understanding of how interventions differ by type of interaction/setting (in-person, phone, virtual; hospital, home, facility)

9 PURPOSE Describe the clinical care documented by a palliative care nurse during the provision of technology-enhanced transitional palliative care using the Omaha System

10 TECHNOLOGY-ENHANCED TRANSITIONAL PALLIATIVE CARE (TPC) INTERVENTION Hospital In-person visit within 24 hours of enrollment, then daily In Home In-person home visit within hours of discharge Weekly virtual visits using ipad during next 8 weeks Intermittent phone calls

11 METHODS Design: Content analysis of TPC intervention nurse notes in clinical record Sample/setting: 9 patients in the study had a total of 109 notes Analysis: Data deductively analyzed using the Omaha System as the organizing framework Unit of analysis was the narrative phrase Methodological rigor maintained using coder agreement, an audit trail and periodic debriefing Counts/proportions of problems, intervention categories, and targets calculated, summarized with means, medians, ranges Comparisons of percentages of problems, intervention and targets between location of visit using chi-square or Fisher exact tests

12 THE OMAHA SYSTEM Standardized terminology that allows us to more readily describe: Patient/family health concepts/problems Nursing interventions Outcomes Used in prior research with discharge planning and APN contributions to transitional care of hospitalized elderly patients (Bowles, 2000; Brooten, Youngblut, Deatrick, Naylor, York, 2003; Naylor, Bowles, Brooten, 2000)

13 THE OMAHA SYSTEM 42 health concepts/problems grouped in 4 domains: 1. Environmental 2. Psychosocial 3. Physiological 4. Health-related Behaviors

14 4 INTERVENTION CATEGORIES 1. Teaching, Guidance, and Counseling (provide information and materials, encourage action and responsibility, assist in making decisions and solve problems) 2. Treatments and Procedures 3. Case Management (coordination, advocacy, and referral) 4. Surveillance (monitoring/assessment)

15 75 TARGETS Unique objects of practitioner activities that serve to further describe interventions Examples: Medication coordination/ordering Bowel care Cast care Support systems Transportation Durable medical equipment

16 INTERVENTIONS Interventions in the Omaha System describe clinicians actions and activities. One intervention (as described in a phrase) is defined by three linked terms: Problem + Intervention Category + Target Phrase Within Clinical Documentation Note Will pick up prescription tomorrow Problem Category Target Health care supervision Case management Medication coordination

17 RESULTS 9 patients randomized to intervention group Gender 2 males, 7 females Age Average 68.7 (±2.7, range 46-87) years Primary diagnosis 8 cancer; 1 respiratory failure Co-morbid conditions Average 7.1 (±5.8, range 2-18) Medications Average 15.4 (±5.9, range 9-27)

18 RESULTS NOTES: Total notes: 109 Notes per patient : mean 12.1 (± 7.9;) median 11; range 3-22 Note origin Number of Notes Notes/Patient Hospital visit 22 mean 2.4; median 2; range 0-10 Home visit 7 mean 0.8; median 1; range 0-2 Phone call 24 mean 2.7; median 2; range 0-6 Virtual visit 24 mean 2.7; median 2; range 0-7 SNF/REHAB/SWING visit 3 mean 0.3; median 0; range 0-1 Clinic/ED visit 13 mean 1.4; median 1; range 0-6 Electronic Message to MD 16 mean 1.8; median 1; range 0-7

19 PHRASES BY TYPE OF VISIT Total phrases 1473 Note origin Number (%) of phrases (N=1473) Average phrases/note Hospital visit (n=22) 234 (15.9) 10.6 Home visit (n=7) 184 (12.5) 26.2 Phone call (n=24) 178 (12.1) 7.4 Virtual visit (n=24) 511 (34.7) 21.2 SNF/REHAB/SWING visit (n=3) 54 (3.7) 18.0 Clinic/ED visit (n=13) 205 (13.9) 15.7 Electronic Message to MD (n=16) 107 (7.3) 6.7

20 EXAMPLES OF PHRASES MAPPED TO THE OMAHA SYSTEM Phrase Domain Problem Category Target Colostomy is working well, denies any problems or Ostomy Physiological Bowel function S concerns. care Writer will contact daughter after the appointment at Rochester. Writer reviewed with patient medication use for pain and constipation. Discussion regarding advanced directives and code status. Patient has not completed an advanced directive as yet. She states that she would not want to live on a machine and when she said this she turned to her family and asked if they understood her wishes. Writer discussed plan of care with PC Doctor Psychosocial Health-related Behaviors Health-related Behaviors Health-related Behaviors Caretaking/ parenting Medication regimen Health care supervision Health care supervision CM TGC TGC CM Nursing care Medication action/side effects End-of-life care Continuity of care S = Surveillance CM = Case Management TGC = Teaching, Guidance & Counseling

21 RESULTS Phrases mapped to all 4 domains Environmental: 38 (2.58%) Health-related Behaviors: 770 (52.3%) Physiological: 454 (30.8%) Psychosocial: 211 (14.3%) 31 of the 42 Omaha System problems identified Average number of problems/ patient:16 (± 6.5) median 19; range of the 4 intervention categories utilized (no Treatments & Procedures) Surveillance: 1067 (72.4%) Case Management: 308 (20.9%) Teaching, Guidance, and Counseling: 98 (6.7%) 50 of the 75 Omaha System targets utilized

22 PATIENTS WITH PROBLEMS IDENTIFIED

23 FREQUENCIES OF PROBLEM PHRASES

24 MOST FREQUENT SYSTEM INTERVENTION TARGETS BY CATEGORY Surveillance Teaching, Guidance, and Counseling Case Management Target N(%) Target N(%) Target No. (%) (n=1067) (n=98) (n=308) Signs/symptomsphysical 264 (24.7) Nursing care (26.5) Nursing care 130 (42.2) Medical/dental care 143 End-of-life care 11 (11.2) Continuity of care 60 (19.5) (13.4) Medication 81 (7.6) Medication 11 (11.2) Medical/dental 36 (11.7) administration administration care Medication action/ side effects 78 (7.3) Dietary management 7 (7.1) Medication coordination/ ordering 21 (6.8) Nursing care: Assessment/diagnosis and treatment provided by nurses and their staff or assistants

25 KEY FINDINGS Problems, intervention categories, and targets significantly differed by note origin Problems: p <0.041 Intervention categories: p <0.001 Targets: p <0.001 Duration between first and last note: Average 32.3 days (median 28; range 4-65) Statistically significant positive correlation between number of problems/patient and duration between first/last note Spearman rank correlation coefficient = 0.76; p=0.016 Number of problems/patient and number of notes was not correlated Spearman rank correlation coefficient = 0.51; p=0.16

26 DISCUSSION First description of a transitional palliative care intervention based on documentation by the intervention nurse mapped to a standardized terminology First opportunity to look at problems & interventions by type of visit These patients have complex nursing needs Compared to other transitional care patient samples: More problems overall (Bowles, 2000; Naylor,Bowles & Brooten, 2000) More problems in Physiological domain (Brooten, Youngblut, Deatrick, Naylor, York, 2003) Similar percentage of interventions in Surveillance category, but more Case Management than Teaching, Guidance, and Counseling (Naylor,Bowles & Brooten, 2000) Each type of interaction contributed to intervention Number of patient problems did not seem to impact number of interactions

27 LIMITATIONS Were able to enroll only a small number of patients Primarily patients with a cancer diagnosis were included

28 IMPLICATIONS Using standardized terminology increases comparability of clinical data across settings and models of care Critical first step in our ability to link problems and interventions with outcomes attributable to the role of the nurse in transitioning palliative care Configuration of problems and interventions inform future studies to determine the optimal model for delivery of transitional palliative care services Future analysis of differences in problems and interventions documented in progress notes and messages to MDs Possibility of combining data from prior transitional care studies that mapped documentation to the Omaha System

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