New Models of Care and Emerging Nursing Roles. Alan Bernstein MS, RN Office of Nursing Services

Transcription

1 Veteran Centered Care New Models of Care and Emerging Nursing Roles Alan Bernstein MS, RN Office of Nursing Services 1

2 Veterans Health Administration (VHA) VISION STATEMENT VHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient centered and evidence based. This care will be delivered by engaged, collaborative teams in an integrated environment that supports learning, discovery and continuous improvement. It will emphasize prevention and population p health and contribute to the nation s well-being through education, research and service in national emergencies. 2

3 Vision of VHA Preventive Care Program The Veteran will experience health promotion and disease prevention (HPDP) clinical interventions that are seamlessly integrated across the continuum of their health care and are delivered in a variety of modalities matched to the Veteran s needs and preferences. VHA clinicians and clinical support staff will value and participate in the delivery of HPDP interventions for patients tailored to each Veteran s priorities and overall plan of care. 3

4 VHA Facilities Statistics (as of 5/11/11) Medical Centers: 152 Community Living Centers 330 Community-Based Outpatient Clinics: 798 Veteran Readjustment Centers: 278 4

5 2010 VA Population Statistics (as of 9/30/10) U.S. Veteran Population: 22.7 million 91.9% males 8.1% females (projected to reach 15% by 2035) VHA Statistics: Enrolled Population: 8.3 million Outpatient Visits: 76 million Inpatient Admissions: 680 million 5

6 Veteran Period of Service Statistics (as of 9/30/10) Vietnam Era: 7.5 million Peacetime only: 5.8 million Gulf War: 5.7 million Korean Conflict: 2.4 million WWII: 2 million Post 9/11 [Operation Enduring Freedom (OEF) / Operation Iraqi Freedom (OIF) / Operation New Dawn (OND)]: 1.3 million [Note: Categories are not mutually exclusive [Note: Categories are not mutually exclusive. Veterans may serve in multiple periods.] 6

7 VA Health Care Utilization: Post 9/11 OEF / OIF / OND Veterans: Approximately 2.2 million have deployed since ,250,663 have separated from service and are eligible for care 50% (625,385) of these have obtained VA health care since FY 2002 (cumulative total) 7

8 What are the health care needs of our returning combat Veterans? 8

9 What are the health concerns of OEF/OIF/OND veterans seen in the VA? 1,250,663 of the million deployed, d are separated and eligible ibl for VA 50 % have been seen in VA between FY02 and December 2010 Musculoskeletal 54.3% Mental disorders 50.2% Symptoms/signs 48.7% Nervous system (hearing) 42.0% GI (dental) 35.1% Endocrine/Nutrition 29.1% Injury/Poisoning 27.3% Respiratory 24.5% VHA Office of Public Health and Environmental Hazards December

10 Co-morbid Concerns in Combat Veterans Lew, Otis, Tun, Kerns, Clark, & Cifu, in review Sample = 340 OEF/OIF outpatients at Boston VA TBI/Pain 12.6% 5.3% 6.8% 10.3% P3 Multi symptom Disorder 42.1% 16.5% Overall prevalence: Pain 81.5% TBI 68.2% PTSD 66.8% PTSD 2. % 10

11 Integrated Post-Combat Care PDICI (Post-Deployment Integrated Care Initiative 2008) Physical Psychological Veteran Psychosocial 11

12 Integrated Post-Combat Care PDICI (Post-Deployment Integrated Care Initiative 2008) Primary Care Provider Mental Health Provider Veteran Social Worker 12

13 Health Care Reform and Nursing 13

14 National Discussion Healthcare Reform Lower Healthcare Costs Provide Affordable and Accessible Health Insurance Coverage Promote Prevention and Stress Public Health 14

15 National Discussion on the Future of Nursing Nursing Shortage Nursing Faculty Nursing Workforce Nursing Practice DNP CNL Informaticist Certification Agenda Lower Costs Population Management EBP Outcomes Quality and Safety Access Prevention Primary Care 15

16 VA Nursing: Influencing national nursing practice 16

17 Institute of Medicine (IOM) The Future of Nursing Affordable Care Act (ACA) Accessible Quality Care Wellness Disease Prevention Interprofessional Collaboration Value of Service Responsive to needs Patient Centered 17

18 Institute of Medicine (IOM) The Future of Nursing Key Messages Practice to the full extent of education Achieve higher levels of education Full partners in redesigning healthcare Improved data collection and information infrastructure 18

19 Institute of Medicine (IOM) The Future of Nursing - Recommendations 1. Remove scope of practice barriers 2. Expand opportunities to lead and diffuse collaborative improvement efforts 3. Implement nurse residency programs 4. Increase BSN to 80% by Double doctorate by Engage in life long learning 7. Enable nurses to lead change to advance health 8. Infrastructure for the collection and anaylis of data 19

20 VA Advanced Practice Registered Nurses (APRN): Nurse Practitioners (NP), Clinical Nurse Specialists (CNS), and Certified Registered Nurse Anesthetists (CRNA) 20

21 APRN Practice All VA APRNs will function as independent professionals regardless of the State t in which h they are licensed. The intent is to reduce variability in practice across the entire VA health care system.

22 APRN Practice Core privileges are based on education and certification and include: Admitting and discharging privileges Basic primary and emergency care Ordering/interpreting diagnostic studies (radiology and lab studies) Referrals and consultations Additional privileges are based on request and demonstration of competency 22

23 VA Registered Nurses (RN): Clinical Nurse Leaders, Primary Care RN, Care Managers, Nurse Informaticists and Tele-Health RNs 23

24 The Clinical i l Nurse Leader: Clinical leadership across the continuum of care 24

25 Clinical Nurse Leader First new master s prepared nursing role introduced in 35 years. A direct care provider prepared to deliver clinical leadership in all health care settings. The goal : Reduce fragmented care, Improve patient outcomes, and Increase patient safety/satisfaction at the Microsystems level 25

26 The CNL Role Is: Unit-based (the Microsystems level) A staff nurse A generalist--not a specialist 26

27 The CNL is not: A Nurse Manager No administrative function Provides clinical leadership and direct care for the most complex patients 27

28 The CNL is not: A Shift Charge Nurse The shift charge nurse is concerned with: The completion of tasks for patients during the shift Ensuring g that staff have the resources they need to complete all patient care on the shift The CNL observes patient care practices and utilizes evidence- based care to improve care 28

29 The CNL is not: A Clinical Nurse Specialist The CNS is a population specialist A CNS impact is greatest working at the Macrosystems level (across the entire facility) 29

30 The CNL is not: A Nurse Educator AN Nurse Educator s primary function is staff education A Nurse Educator works with the CNL to design/provide staff education to enhance patient t care outcomes 30

31 The CNL is not: A Case Manager A Case Manager s emphasis is on the medical plan of care to ensure continuity it of care: Post-discharge Among multiple providers and care settings, and Ensure the patient s care is uninterrupted 31

32 The CNL is not: A Discharge Planner The Discharge Planner works with the CNL and Case Manager to ensure the patient: Is transferred to the appropriate care setting upon discharge Has the necessary supplies and equipment for home care The CNL participates and may lead discharge planning for select patients 32

33 GI Protocol CNS CNL Developed protocol Approval by hospital administration Conducted staff education Developed criteria for quality monitoring Revised protocol based on evaluation Identified need for a protocol Coordinated d staff education Implemented protocol Conducted quality monitoring Evaluated results 33

34 Staff Education: Insulin CNS CNL Identified problem Coordinated staff Conducted staff education education sessions Conducted d quality Developed criteria for monitoring quality monitoring Evaluated QM results Evaluated QM results Conduct ongoing staff education sessions 34

35 Potential CNL Outcomes: Reduce Falls and Pressure Ulcers Monitor care of complex patients Teach /mentor novice nurses in all specialty care Evaluate pain management in elderly post-ops Successful diabetic self- management Coordination of care between care settings 35

36 Demonstrated t CNL Outcomes: Quality, Financial, and Innovation 36

37 CNL Outcomes Domain Indicator Outcome Financial Nursing Hours Per Patient Day (NHPPD) Increased by 8.63% within 1yr Quality Processes 1. Pressure Ulcers Decreased from 12.5% to 4.2% 2. Patient Falls Decreased from 1.93 to 1.37 in 3 months Innovations 3. Discharge Teaching 4. Ventilator Associated Pneumonia 5. CLC Restorative Care Factors Journalized CNL entries in innovative practices Increased compliance from 13% to 100% Decreased from 21.7% to 87% 8.7% Increased by 8% in the 1 st month Revealed team collaboration to reduce care fragmentation, customize care, & engage MDs 37

38 Colonoscopy Screening Cancellations CNL assessed high rate of no-shows and cancellations CNL contacted t patients t to confirm tests t and review pre-procedure instructions Results: No-show h rate decreased d from 30% to 14% 38

39 Ambulatory Surgical Procedure Cancellations Assessment of cancellations revealed patient-related reasons (not NPO; need to reschedule) CNL confirmed pre-op date/instructions prior to posting surgery schedule Results: 14.4% 4% cancellation rate in 2006 dropped to 11.4% in 2007 at an estimated costavoidance of $462K Cancellation rate in 2008 dropped to 9.4% CNL continued to improve surgical efficiencies in collaboration with an interdisciplinary group 39

40 Innovations New Initiatives Evidence-Based Practice Activity Staffing Changes Role Conversions Changes in Staff Skills Education Mix Academic Affiliations 40

41 The RN Care Manager Role in the Primary Care Patient Aligned Care Team (PACT) Model 41

42 PCMH Four Major Operational Components Care Coordination & Care Management Team Function and Culture Patient Centeredness Enhance Access Enhance Coordination Enhance Efficiency Enhance Comprehensive Care 42

43 Primary Care Team Functions Administrative Support Care Coordination Comprehensive Care Delivery Professional Development Organizational Management Program Management g Face -to-face Encounters Non Face- to FaceEncounters Team Management a age e t TASKS Clerk LPN Health Tech/ NA RN Care Manager Social S i l Work W k Specialists Providers The Team Teamlet The Team Teamlet Facility L d hi Leadership PC Management 43

44 Patient Aligned Care Team CNL RN Care Manager Veteran NP CNS Direct Patient Care Scheduled visits Telephone Visits Assess educational level of pts/families to create self mgmt strategies Inpt/home visits Work W kwith PCMH vulnerable populations Secure Messaging Triaged pt messages E mail w/consultants Care Management Needs assessment of the PCMH organization Revise protocols Track/trend disease data to improve pt outcomes Identify strategies to improve RN practice Applies EBP to RN care Team Work Team Meetings Education Mentor RN Care Mgr Precept nurse trainees Direct Patient Care Scheduled, walk in or urgent Visits Group/telephone Visits Triage/protocol orders Pt Education Secure Messaging Triaged messages from patients E mail with consultants Care Management Virtual/F2F in depth and ongoing pt review including inpatients Identify high risk for hospitalization. Initiate consults for CM, home care, hospice, specialty nursing care Preventive/DM care F/U VA & non VA care Team Work Daily huddle Team Meeting Education Mentor/precept nurse trainees Schedule appointments As needed or requested by primary care team Appt check in Utilizes kiosk to check in Updates insurance & demographic info Face to Face Visits Bring medications Health risk assessment completion w/ RN Complete Lab work Prepare for Visitit Discuss concerns and plan of care Contact team w/concerns Participate i t Committees & pt Direct Patient Care Scheduled Clinic Visits Walkin /Urgent Visits Group / Telephone Visits Clinical Reminders Secure Messaging Triaged pt messages E mail with consultants Care Management Virtual review of pts including inpatients Identify high risk for hosp. For CCHT, OEF/OIF, HBPC Preventive care needs Non VA records View alerts Diagnostic result Discuss care with/refer to specialty consultants Traveling veterans Medication Reconciliation Refer as appropriate Team Work Daily huddle Team Meeting Physician collaboration Education New patient orientation Provider CME, Grand Rounds Teaching trainees Direct Patient Care Provides specialty assessment and care. Secure Messaging Triage messages from patients with/from other consultants Care Management Consulted by RN Care Manager or CNL for specialty assessment Provide assistance with plan of care development Coordinate/Conduct group visits with specialty populations Identify additional services needed by Veteran/Family Team Work Team meetings Education 44 Augment pt teaching

45 Patient Complexity Complexity, Health Status Status, Needs Medical Home Team Coordination of Care Specialty Care Clinical Nurse Leader, Case Managers, Clinical Pharmacists Disease/Cohort Management Management of Care 45

46 Provider/RN Care Manager Clinical Tasks Clinical Tasks Direct Patient Care Care Management Scheduled Clinic Visits Group Visits Telephone Visits Incoming calls Walk in or Urgent Visits Pertinent Clinical Reminders Ordering diagnostic tests Ordering consults Od Ordering medication Virtual review of patients Identify high risk for hospitalization Determine appropriateness for CCHT, OEF/OIF, HBPC Preventive enti e care needs Non VA records View alerts Diagnostic result Discuss care with/refer to specialty consultants Traveling veterans Medication Reconciliation 46

47 Provider/RN Care Manager/Clinical Support Clinical/Administrative Tasks Clinical/Administrative Tasks Education New patient t orientation Patient/family teaching Mentor/precept trainees Other Secure Messaging Triage messages Respond to triaged messages with consultants Team Work Daily huddle Team meeting 47

48 RN Care Manager Role and Responsibilities Gatekeeper for all care needs Knows the role of the teamlet and team members Applies critical thinking skills to identify barriers to care Promotes patient and staff safety Collaborates with the pt/family, teamlet and expanded team to develop the patient-driven holistic care plan Smooth transitions by collaborating with multidisciplinary services, internal and external Education/Coaching to support self-management, prevention, and wellness, based on patients t goals 48

49 PACT RN Care Manager Providing the right care at the right time by the right person at the right place Puts Veteran and family at the center and they are engaged and share in decision making and goal setting Coordinates care and facilitates care plan Assure that all Veterans have info and access to VA system/pact and the OEF/OIF/OND program Keeps all members of the Veteran s team on the same page 49

50 PACT RN Care Manager Providing the right care at the right time by the right person at the right place Partners with OEF/OIF/OND team to assure needs are met and care coordinated d Understands resources and how to access Facilitates seamless handoffs Facilitates shared decision making Assures that Veteran knows who is on the team Promotes health and well being reaching out 50 to nurture relationships

51 Patient Aligned Care Team for Returning Combat Veterans Patient centered, team based, integrated care Evidence based, continuously improving care Communication Combat Veteran Care/Case Manager Collaboration Coordination P t C b t C PACT f d Post-Combat Care moves our PACTs forward The PACTs move our Post-Combat Care forward 51

52 Implications for RN Care Managers Coordinate HPDP services for patient panel Offer and provide other clinically appropriate preventive services (screening tests, other health behavior counseling, immunizations and preventive medications) Endorse healthy living i messages and respond to questions from patients 52

53 Support for RN Care Managers Training Programs and Support in Patient-Centered Communication Patient Education: TEACH for Success Motivational Interviewing Tools and Resources Websites ( Clinical staff reference tools Patient tools Documentation tools MOVE! Weight Mgmt. Program Facility HPDP Program Committee 53

54 Clinical Staff Guide to Healthy Living Messages 54

55 Clinical Staff Guide to Health Coaching 55

56 Coming Attractions: Healthy Living Materials 56

57 Nurse Informaticists: ADPAC Automated Data Processing Applications Coordinator CAC Clinical Applications Coordinator PI/IS Coordinator Performance Improvement/Information Systems Coordinator BCMA Coordinator Bar Code Administration i ti Coordinator 57

58 Nursing Informaticists Nursing Informatics integrates nursing science, computer and information science and cognitive science to manage, communicate and expand the data, information, knowledge and wisdom of nursing practice. ( ANA 2008) 58

59 Nurse Informaticists Computers are incredibly fast, accurate and stupid. Human beings are incredibly slow, inaccurate and brilliant. Together they are powerful beyond imagination. Albert Einstein 59

60 Telehealth Nursing The use of information and communication technology to deliver health services, expertise and information over distance Constant with the principles of primary healthcare Di ti di i d Disease prevention, diagnosis and treatment 60

61 Telehealth Nursing Assessment and triage Provision of health information Health counseling and teaching Elicit patient concerns Listening and providing support 61

62 Other Roles to Consider Travel Nurse OR Pediatrics Critical Care Nurse Educator MSN PhD, DNP Nurse Administrator Nurse Manager CNO 62