Amanda L. Pelock Senior Project, University of Wisconsin - Oshkosh

Amanda L. Pelock Senior Project, University of Wisconsin - Oshkosh

Program Background 3 Problem & Purpose Statement and Main Research Question 4 Stakeholders in the Project 5 Expected Outcomes 6 Other Research about Shared Plans of Care 7 Data Gathering 8 Survey Questions & Results 9 Analysis of Survey Results 18 Additional Questions 21 Survey Outcome 22 References 23

Our program cares for children with medical complexity. To stay up to date on our patients and their changing care, we see try to see them outpatient at least every six months for a clinic appointment. Within two weeks of the visit, the patient will receive a very detailed Shared Plan of Care (SPC). This SPC is very important to the patient and their families. It is even more vital to the patient's primary care provider, outside facilities, emergency rooms, and their local EMS. For these reasons it is important to have this SPC updated at a minimum of every six months. If this does not happen, there is a high probability that we could be fined by the state. The current problem is this is not being finished within two weeks or updated every six months. We have recognized this is an issue and we need to come up with a feasible plan, and in a short amount of time. We are currently grant funded and are working with the state to continue to receive funding so that our program can continue to grow, and provide excellent patient care. We have a couple months to finish our negotiations with the state, but we already know that one of the requirements will be that we have a completed SPC two weeks after seeing the patient, and that it is updated every six months. Everyone on our team recognizes that we have a problem and a deadline that continues to get shorter.

Problem statement: This study will explore how to improve the SPC process to ensure compliance with the state. Purpose statement: The purpose of this study is narrow down what the issues are, and how the SPC can be completed two weeks after the clinic visit, and updated at least every six months. Main research question: What can be done to assist the providers in being compliant in completing the shared plans of care in the required time frame?

The main stakeholders in this project will be the providers that are completing the SPC for their patients. This includes: medical doctors, nurse practitioners, and registered nurses.

A new feasible plan in place to aid in making sure that the SPC is completed every six months, and within two weeks of seeing the patient. The new process will continue to provide exceptional patient care. Patients and parents will be more satisfied, because they will receive the SPC in a more timely manner. Our program will continue to succeed and will be in good graces with the state, and will not receive any fines for being noncompliant.

There is an overwhelming amount of support and research for the SPC. Research has shown that parents feel more confident having an updated SPC in front of them to present to the primary care provider, EMS, local emergency rooms, ect. They could have this SPC in paper form, email, or on a flash drive Parents also felt that it was vital that the SPC was updated often, especially as their child s medical needs change often and quickly. (Adams, et al., 2013, p. 5) There is also an overwhelming amount of research on how easily providers that care for this patient population become burnt out. Providers are not taught on how to delegate tasks, and often are overburdened with patient numbers and the workload. These providers are caring for very sick, mostly terminal children. They tug at your heart strings pretty quickly, and it is easy to get consumed and wrapped up in their care, that burn out can happen quickly. When all of these things happen, the providers progress takes a nose dive pretty quickly, which then also hinders getting the SPC done in a timely manner from when they saw the patient, or when something major might have changed in the child s health (Bartlett, 1999, p. 1-3)

A survey was sent to 20 participants. 4 medical doctors, 6 nurse practitioners, and 6 registered nurses. Out of the 20 participants, 15 responded and provided valuable and honest feedback. The participants were asked to answer a series of 10 questions.

Question 1: What is your profession? Out of the 15 responses, 3 were medical doctors, 6 were nurse practitioners, and 6 were registered nurses. Question 2: Which of the following categories best describes your employment status? Out of the 15 responses, 13 are employed working full-time, and 2 are employed working part-time.

Question 3: How satisfied are you with the current process of completing the SPC? 15 out of 15 answered this question. The following is the satisfaction level of the employees. 1 is strongly satisfied, 7 satisfied, 4 are neutral, and 3 are unsatisfied. 46.67 % 26.67 % 20 % 6.67 % 0 % Strongly Satisfied Satisfied Neutral Unsatisfied Strongly Unsatisfied

Question 4: Are there other elements that you feel should be included in the SPC? 15 out of 15 answered this question. 8 answered no, and 7 answered yes and also included suggestions. No Yes The following are suggestions from 7 employees on other elements that should be included in the shared plan of care: More specific goals. List disciplines of physicians after the physician names on the care team. Family goals, social issues that impact health of child and well being of family transportation, medical understanding, barriers to medical compliance. Detailed plan for meeting care coordination needs (currently part of nurse note). I would love to see it be problem-based, so every problem on the problem list was represented with a plan and person/team responsible. Functional/developmental assessment. More details about updates that have been completed within the care plan. Level of ability (feed self, g-tube dependant, verbal vs. nonverbal, ect).

Question 5: How often do you feel the SPC should be updated? 15 out of 15 answered this question. 80% believed that it should be updated every six months. 13% felt this should be done every two months. 7% felt this should be done every twelve months. Every twelve months 7% Every two months 13% Every six months 80% Every two months Every six months Every twelve months

Question 6: Suggestions on other ways the SPC can be updated? All 15 participants responded to this question. Please refer to the graph below: Check boxes with multiple options for updating the plan By phone with the parent/patient A CHW approved online video communicaton tool 5 11 9 33.33 60 73.33 The following are suggestions from the other category: Shared visits with other services. Updating every six months at follow ups works well. When the patient is inpatient 12 80 Don't change anything 1 6.67 Other (please specify) 2 13.33 0 10 20 30 40 50 60 70 80 90 Number of responses Percent of responses

Question 7: What is the best way to share the SPC with key stakeholders (those being their Primary Care Provider, other specialists, parents ect)? They were asked to select all that apply. All 15 participants responded. Please see the graph for the break down. 100 90 80 93.33 The following is a suggestions from the other category: 70 60 50 40 46.67 40 I would like to see them sent a modified version of the SPC via MyChart. 30 20 10 0 7 6 14 6.67 Mail Fax Electronically Other (please specify) 1 Percent of responses Number of responses

Question 8: Average amount of hours it takes you to finish a SPC? 14 out of 15 participants responded to this question. The range for assessment appointments was: 1 to 8 hours. The range for follow up appointments was: 30 minutes to 4 hours.

Question 9: Current barriers that delay completing the SPC within the required time frame. Providers were asked to rank by importance. 1 being the most likely, and 5 being the least likely. This question had a 100% response rate. Time management came in as the biggest barrier. Patient load is too overwhelming came in second. Too much time is spent inpatient, and not all the information in the shared plan of care is of value tied. Personal/family life came in last. Time management 30% Patient load is too overwhelming 25% Personal/Family life Personal/Family life 11% Too much time is spent inpatient 17% Not all of the information in the shared plan of care is of value Too much time is spent inpatient Patient load is too overwhelming Time management Not all of the information in the shared plan of care is of value 17%

Question 10: Other ways that might assist in getting the SPC done in a timely manner by all providers. Providers were asked to rank by importance on what they would like to see changed. 1 being the most important, and 5 being the least important. All 15 participants answered this question. All of the answers were pretty close as far as rank, which means that there really is not an anonymous opinion of what should be changed. The top answer was to set aside specific time for documentation only. Laptops at all clinic visits Re-visit the dispersion of who does what part of the plan needs to be discussed Specific time set aside for documentation only Change the structure of the inpatient and outpatient schedule Allow more time between clinic appointments

The answers from this survey were in some ways surprising, and in others it helped solidify what we already knew. It was a little surprising to see the large number of providers that are satisfied with the current process of completing the SPC. 47% of the participants stated they were satisfied with the current way. Due to the fact that the SPC is not being done in a timely manner, we thought for sure the data would have shown that we have to change our process significantly. Our current process is to update the every six months SPC. Although this is not always being done, it was encouraging to see that providers are open to other ways of completing the SPC. Such as doing it when the patient is inpatient, online video, and surprisingly 80% were okay doing it via phone. Since the providers struggle to also get the SPC updated every six months, the findings from this question will be helpful to insure the providers complete the SPC at a minimum of every six months, and that providers are open to other ways of doing it, instead of our usual way of face to face in clinic. Research has shown that it is important to parents to have a SPC for their medically complex child, and that it is updated often, as their cares frequently change.

One of the nurse practitioners asked that the question be included on how the providers feel we should share the plan of care with our key stakeholders (those being primary care providers, other specialists, parents, ect.). Almost 94% of the providers feel we should share it electronically. Our current process to primary care providers and specialists is electronically if we are able, otherwise we fax it. We mail all copies to the parents. One provider provided great feedback that they would like to share it via MyChart. It might be helpful to share the SPC via MyChart or in another electronic form for the parents. This way they not only have a paper copy mailed to them, they also have it electronically to quickly show someone, such as the emergency room. It is helpful to see the range of how long on average it is taking the providers to do their notes. When analyzing the data, question 8 should have been asked a little bit differently, to help break down if it was a registered nurse or a nurse practitioner/medical doctor doing the note, as the NP/MD has a much larger portion of the note to do. This question was not carefully thought out.

The state is mandating that for every patient in the program they need their SPC updated every six months, and finished within two weeks of seeing the patient. Currently this a struggle for most providers to meet this deadline. It is vital that we come up with a solution in order to stay in the good graces of the state, and not receive any fines. It was suspected that a large portion of the issue is due to poor time management. This survey confirmed those suspicions. Time management was the most common chosen answer. Closely followed by this was that they felt heir patient load is to overwhelming, and too much time is spent doing inpatient work. In order to best help the providers, the program wanted to know what was important to the providers, and what changes should be made to the current process. The category that got the most attention was the providers would like specific time set aside for documentation only. Closely followed by that was to change the structure of the inpatient and outpatient schedule and revisit who does what part of the SPC.

How many unfinished notes do you have that are over the two week time frame? Do you currently feel burned out at your job? If you answered yes, what steps can the program do to help you?

The results of the survey have been shared already with the program medical director and manager. Because of this survey they have started to implement some of the providers suggestions. They have revamped the inpatient and outpatient schedule in hopes that it will help them with their time management. They have also scheduled in specific documentation time to help them have enough time set aside to finish the SPC. At this time, it is unknown how supportive and helpful these changes to the process will be. Now that they have implemented some changes; ones that the providers have requested, the program is hopeful that they will see a change, hopefully in a positive way.

Adams, S., Cohen, E., Mahant, S., Friedman, J. N., Macculloch, R., & Nicholas, D. B. (2013). Exploring the usefulness of comprehensive care plans for children with medical complexity (CMC): a qualitative study. BMC Pediatrics, 13(1). doi:10.1186/1471-2431-13-10. Retrieved from: http://bmcpediatr.biomedcentral.com/articles/10.1186/1471-2431-13-10 Bartlett, E. E. (1999). Always Running Behind? Try These Time Management Tips. Medical Economics, 76(4), 83-91. Retrieved from: http://search.proquest.com.www.remote.uwosh.edu/docview/227814903 OpenUrlRefId=info:xri/sid:primo&accountid=9355