Veteran Centered CareVeteran Centered CareNew Models of Care and Emerging Nursing Roles

Alan Bernstein MS, RNOffice of Nursing g

Services

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Veterans Health Administration (VHA)VISION STATEMENTVISION STATEMENT

VHA ill ti t b th b h k f llVHA will continue to be the benchmark of excellence and value in health care and benefits by providing exemplary services that are both patient centered p y pand evidence based.

This care will be delivered by engaged, collaborative teams in an integrated environment that supportsteams in an integrated environment that supports learning, discovery and continuous improvement.

It will emphasize prevention and population health p p p pand contribute to the nation’s well-being through education, research and service in national emergenciesemergencies.

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Vision of VHA Preventive Care Program

The Veteran will experience health promotion and disease prevention (HPDP) clinical interventions that are seamlessly integrated across the continuumthat 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 supportpreferences. 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.

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VHA Facilities Statistics (as of 5/11/11)

• Medical Centers: 152• Medical Centers: 152

• Community Living Centers 330

• Community-Based Outpatient Clinics: 798

• Veteran Readjustment Centers: 278

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2010 VA Population Statistics (as of 9/30/10)(as of 9/30/10)

• U.S. Veteran Population: 22.7 millionU.S. Veteran Population: 22.7 million91.9% males8 1% females (projected to reach 15% by8.1% females (projected to reach 15% by

2035)

• VHA Statistics:Enrolled Population: 8 3 millionEnrolled Population: 8.3 million Outpatient Visits: 76 million Inpatient Admissions: 680 millionInpatient Admissions: 680 million

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Veteran Period of Service Statistics (as of 9/30/10)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

VA Health Care Utilization: Post 9/11

OEF / OIF / OND Veterans:• Approximately 2.2 million have deployed since

2002• 1,250,663 have separated from service and

are eligible for care• 50% (625,385) of these have obtained VA

health care since FY 2002 (cumulative total)

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

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What are the health concerns of OEF/OIF/OND veterans seen in the VA?of OEF/OIF/OND veterans seen in the VA?

1 250 663 f th 2 2 illi d l d t d d li ibl f VA1,250,663 of the 2.2 million deployed, are separated and eligible for VA50 % have been seen in VA between FY02 and December 2010

• Musculoskeletal 54.3%• Mental disorders 50.2%• Symptoms/signs 48.7%

N t (h i ) 42 0%• Nervous system (hearing) 42.0%• GI (dental) 35.1%• Endocrine/Nutrition 29.1%• Injury/Poisoning 27 3%Injury/Poisoning 27.3%• Respiratory 24.5%

VHA Office of Public Health and Environmental Hazards December 2010

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Co-morbid Concerns in Combat Veterans

Lew, Otis, Tun, Kerns, Clark, & Cifu, in reviewSample = 340 OEF/OIF outpatients at Boston VA

TBI/Pain12.6%

P3 Multi‐symptom

5.3%10.3%

symptomDisorder42.1% 16.5%6.8%

Overall prevalence:Pain 81.5%TBI 68 %

PTSDTBI 68.2%PTSD 66.8%

2. %

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Integrated Post-Combat CarePDICI (Post Deployment Integrated Care Initiative 2008)PDICI (Post-Deployment Integrated Care Initiative 2008)

PhysicalPhysical Psychological Psychological

Veteran

Psychosocial Psychosocial

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Integrated Post-Combat CarePDICI (Post-Deployment Integrated Care Initiative 2008)PDICI (Post Deployment Integrated Care Initiative 2008)

Primary CarePrimary CarePrimary Care Primary Care ProviderProvider

Mental HealthMental HealthProvider Provider

Veteran

Social WorkerSocial Worker

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Health Care Reform and

N iNursing

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National Discussion

Healthcare Reform• Lower Healthcare Costs• Provide Affordable and Accessible Health

Insurance Coverage• Promote Prevention and Stress Public Health

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National Discussion on the Future of NursingNursing

Nursing Shortage AgendaNursing Shortage

• Nursing Faculty• Nursing Workforce

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• Lower Costs• Population Management• Nursing Workforce

Nursing Practice

Population Management• EBP• OutcomesNursing Practice

• DNP• CNL

• Quality and Safety• Access

• Informaticist• Certification

• Prevention• Primary Care

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VA Nursing:VA Nursing: Influencing national

i inursing practice

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Institute of Medicine (IOM)The Future of NursingThe Future of Nursing

• Affordable Care Act (ACA)• Accessible Quality Care• Wellness• Disease Prevention• Interprofessional Collaboration• Value of Service• Responsive to needs• Patient Centered

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Institute of Medicine (IOM)The Future of Nursing – Key MessagesThe 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

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Institute of Medicine (IOM)The Future of Nursing - RecommendationsThe Future of Nursing Recommendations

1 Remove scope of practice barriers1. Remove scope of practice barriers2. Expand opportunities to lead and diffuse

collaborative improvement efforts3 I l t id3. Implement nurse residency programs4. Increase BSN to 80% by 20205 Double doctorate by 20205. Double doctorate by 20206. Engage in life long learning7. Enable nurses to lead change to advance

healthhealth8. Infrastructure for the collection and anaylis of

data

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VA Advanced Practice Registered Nurses (APRN):Registered Nurses (APRN):

Nurse Practitioners (NP), Clinical N S i li (CNS) dNurse Specialists (CNS), and

Certified Registered Nurse gAnesthetists (CRNA)

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APRN Practice

• All VA APRNs will function as• All VA APRNs will function as independent professionals

dl f th St t i hi h thregardless of the State in which they are licensed. The intent is to reduce variability in

practice across the entire VA healthpractice across the entire VA health care system.

APRN Practice

• Core privileges are based on education and tifi ti d i l dcertification and include:

Admitting and discharging privilegesBasic primary and emergency careOrdering/interpreting diagnostic studies

( di l d l b t di )(radiology and lab studies)Referrals and consultations

• Additional privileges are based on request and demonstration of competencyand demonstration of competency

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VA Registered Nurses (RN):VA Registered Nurses (RN):Clinical Nurse Leaders, Primary Care RN, Care Managers, Nurse

Informaticists and Tele-Health RNsInformaticists and Tele Health RNs

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Th Cli i l N L dThe Clinical Nurse Leader: Clinical leadership across the p

continuum of care

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Clinical Nurse LeaderClinical Nurse Leader

Fi t t ’ d i lFirst 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 careReduce fragmented care, Improve patient outcomes, and Increase patient safety/satisfaction at theIncrease patient safety/satisfaction at the

Microsystems level25

The CNL Role Is:

Unit-based (the Microsystems level)level)

A staff nurse

A generalist--not a specialistA generalist--not a specialist26

The CNL is not: A Nurse Manager

• No administrative function

• Provides clinical leadership and direct care for the most complex patientsp

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The CNL is not: A Shift Charge NurseNurse • The shift charge nurse is

concerned with:The completion of tasks for patients duringThe completion of tasks for patients during

the shiftEnsuring that staff have the resources they g y

need to complete all patient care on the shift

• The CNL observes patient care practices and utilizes evidence-practices and utilizes evidencebased care to improve care 28

The CNL is not: A Clinical Nurse SpecialistSpecialist

• The CNS is a population specialist

• A CNS’ impact is greatest working at the Macrosystems level (across the entire facility) y)

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The CNL is not: A Nurse EducatorEducator

A N Ed t ’ i• A Nurse Educator’s primary function is staff education

• A Nurse Educator works with the• A Nurse Educator works with the CNL to design/provide staff

d ti t h ti teducation to enhance patient care outcomes

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The CNL is not: A Case ManagerManager

• A Case Manager’s emphasis is on• A Case Manager s emphasis is on the medical plan of care to ensure

ti it fcontinuity of care: Post-discharge Among multiple providers and care

settings, andg ,Ensure the patient’s care is

uninterrupteduninterrupted31

The CNL is not: A Discharge PlannerPlanner• The Discharge Planner works with

the CNL and Case Manager to ensure the patient:ensure the patient:Is transferred to the appropriate care

setting upon dischargesetting upon dischargeHas the necessary supplies and equipment

for home care

• The CNL participates and may lead discharge planning for selectdischarge planning for select patients 32

GI Protocol

• CNS • CNL– Developed protocol

• Approval by hospital administration

– Identified need for a protocolC di t d t ffadministration

– Conducted staff education

– Coordinated staff education

– Implemented protocol– Developed criteria for

quality monitoring– Revised protocol

– Conducted quality monitoring

– Evaluated resultsRevised protocol based on evaluation

– Evaluated results

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Staff Education: Insulin

• CNS • CNL– Identified problem– Conducted staff

d ti i

– Coordinated staff educationC d t d liteducation sessions

– Developed criteria for quality monitoring

– Conducted quality monitoring

– Evaluated QM results– Evaluated QM results – Conduct ongoing staff

education sessionseducation sessions

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Potential CNL Outcomes:

Reduce Falls Monitor care ofand Pressure Ulcers

Monitor care of complex patients

Teach /mentor novice nurses in

Evaluate pain management innovice nurses in

all specialty caremanagement in elderly post-ops

Successful diabetic self-

t

Coordination of care between

ttimanagement care settings35

D t t d CNL O tDemonstrated CNL Outcomes: Quality, Financial, and InnovationQ y, ,

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CNL Outcomes

Domain Indicator Outcome

Financial Nursing Hours Per Patient Day (NHPPD)

Increased by 8.63% within 1yr

Q lit 1 Pressure Ulcers Decreased from 12 5% toQuality Processes

1. Pressure Ulcers

2. Patient Falls

Decreased from 12.5% to 4.2% Decreased from 1.93 to 1.37 in 3 months

3. Discharge Teaching

4. Ventilator Associated Pneumonia

Increased compliance from 13% to 100%

Decreased from 21.7% to 8 7%Pneumonia

5. CLC Restorative Care Factors

8.7% Increased by 8% in the 1st

month

Innovations Journalized CNL entries in innovative practices

Revealed team collaboration to reducein innovative practices collaboration to reduce care fragmentation, customize care, & engage MDs

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Colonoscopy Screening CancellationsCancellations

• CNL assessed high rate of no-shows and cancellationsCNL t t d ti t t fi t t d• CNL contacted patients to confirm tests and review pre-procedure instructions

Results:N h t d d fNo-show rate decreased from

30% to 14%

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Ambulatory Surgical Procedure CancellationsProcedure Cancellations

• Assessment of cancellations revealed patient-related reasons (not NPO; need topatient related reasons (not NPO; need to reschedule)

• CNL confirmed pre-op date/instructions prior to posting surgery scheduleprior to posting surgery schedule

Results:14 4% cancellation rate in 2006 dropped14.4% cancellation rate in 2006 dropped

to 11.4% in 2007 at an estimated cost-avoidance of $462KCancellation rate in 2008 dropped toCancellation rate in 2008 dropped to

9.4%CNL continued to improve surgical

efficiencies in collaboration with anefficiencies in collaboration with an interdisciplinary group

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Innovations

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

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Th RN C M R lThe RN Care Manager Role in the Primary Care Patient Aligned y g

Care Team (PACT) Model

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PCMHFour Major Operational ComponentsFour Major Operational Components

CareTeam Function

and Culture

Care Coordination &

Care Management

PatientPatient CenterednessCenteredness

g

EnhanceEnhance Access Enhance

Coordination Enhance EfficiencyEnhance

Comprehensive Care 42

Primary Care Team Functions

•Comprehensive Care Delivery

Professional Development

Care Coordination

AdministrativeSupport

Organizational Management

Face -to-Face Encounters

Program Management

Non Face- to Face-Encounters

Encounters g

Team Management

TASKSa age e t

•RN Care ManagerS i l W k

•Facility L d hi

•Clerk •LPN

•The Team•Teamlet

•Social Work•Specialists•Providers

Leadership•PC Management

•LPN•Health Tech/ NA

•The Team•Teamlet 43

PatientPatient Aligned Care TeamAligned Care Team

RN Care ManagerRN Care ManagerCNLCNL VeteranVeteran NPNP CNS 

Direct Patient Care•Provides specialty  

Direct Patient Care•Scheduled, walk in or urgent Visits

Schedule appointments

Direct Patient Care•Scheduled visits•Telephone Visits

Direct Patient Care•Scheduled Clinic Visits•Walk in /Urgent Visits

assessment and care.

Secure Messaging•Triage messages from patients•Email with/from other

urgent Visits•Group/telephone Visits•Triage/protocol orders•Pt Education

Secure Messaging•Triaged messages from

appointmentsAs needed or requested by primary care team

Appt check inUtilizes kiosk to

•Telephone Visits•Assess educational level of pts/families to create self‐mgmt strategies•Inpt/home visitsW k ith PCMH

Walk in /Urgent Visits•Group / Telephone Visits•Clinical Reminders

Secure Messaging•Triaged pt messages •E‐mail  with consultants

•Email with/from other consultants

Care Management•Consulted by RN Care Manager or CNL for 

•Triaged messages from  patients•E‐mail  with consultants

Care Management•Virtual/F2F in‐depth and ongoing pt review

•Utilizes kiosk to check in •Updates insurance & demographic info

Face to Face VisitsBring medications

•Work with PCMH vulnerable populations

Secure Messaging•Triaged pt messages•E‐mail w/consultants

Care Management•Virtual review of pts including inpatients •Identify high risk for hosp.•For CCHT, OEF/OIF, HBPC•Preventive care needs g

specialty assessment •Provide  assistance with plan of care development•Coordinate/Conduct group visits with specialty 

ongoing pt review including inpatients •Identify high risk for hospitalization.•Initiate consults for CM, home care, hospice, specialty nursing care

•Bring medications•Health risk assessment completion w/ RN•Complete Lab work 

P f Vi it

Care Management•Needs assessment of the PCMH organization•Revise protocols•Track/trend disease data to improve pt 

•Non VA records•View alerts•Diagnostic result•Discuss care with/refer to specialty consultants•Traveling veterans•Medication Reconciliation

populations•Identify additional services needed by Veteran/Family

TeamWork

specialty nursing care•Preventive/DM care •F/U VA & non‐VA care

Team  Work•Daily huddle•Team Meeting

Prepare for Visit•Discuss concerns  and plan of care•Contact team w/concerns 

P ti i t

p poutcomes•Identify strategies to improve RN practice•Applies EBP to RN care

Team  Worki

Medication Reconciliation•Refer as appropriate 

Team  Work•Daily huddle•Team Meeting•Physician collaboration

Team Work•Team meetings

Education•Augment pt  teaching

•Team Meeting

Education•Mentor/precept nurse trainees

Participate•Committees & pt

•Team Meetings

Education•Mentor RN Care Mgr•Precept nurse trainees

Education•New patient orientation•Provider CME , Grand Rounds•Teaching trainees

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Patient Complexity Health Status NeedsPatient Complexity Health Status NeedsPatient Complexity, Health Status, NeedsPatient Complexity, Health Status, Needs

Medical Home Team Specialty Care

Clinical Nurse Clinical Nurse Leader,Leader,

Case Managers, Case Managers, Clinical Clinical

PharmacistsPharmacistsCoordination

of Careof Care

Management of CareManagement of Care

Disease/Cohort ManagementDisease/Cohort Management

Management of CareManagement of Care

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Provider/RN Care ManagerClinical TasksClinical Tasks

Direct Patient Care C M tDirect Patient Care

• Scheduled Clinic Visits• Group Visits

Care Management

• Virtual review of patients• Identify high risk for p

• Telephone Visits• Incoming calls• Walk in or Urgent Visits

y ghospitalization

• Determine appropriateness for CCHT, OEF/OIF, HBPC Pre enti e care needs• Pertinent Clinical Reminders

• Ordering diagnostic tests• Ordering consults

O d i di ti

• Preventive care needs • Non VA records • View alerts • Diagnostic result• Ordering medication • Diagnostic result • Discuss care with/refer to

specialty consultants • Traveling veterans g• Medication Reconciliation

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Provider/RN Care Manager/Clinical SupportClinical/Administrative TasksClinical/Administrative Tasks

Education

N ti t

Secure Messaging

Triage

Team Work

• New patient orientation

• Patient/family teaching

• Triage messages

• Respond to triaged

• Daily huddle • Team meeting

teaching • Mentor/precept

traineesOth

triaged messages

• E-mail with consultants• Other consultants

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RN Care Manager Role and RN Care Manager Role and ResponsibilitiesResponsibilitiesResponsibilitiesResponsibilities

• “Gatekeeper” for all care needsGatekeeper 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 andCollaborates with the pt/family, teamlet and

expanded team to develop the patient-driven holistic care plan

• Smooth transitions by collaborating with• Smooth transitions by collaborating with multidisciplinary services, internal and external

• Education/Coaching to support self-management, ti d ll b d ti t lprevention, and wellness, based on patients goals

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PACT RN Care Manager

Providing the right care at the right time by th i ht t th i ht lthe right person at the right place

• Puts Veteran and family at the center and they are engaged and share in decisionthey are engaged and share in decision making and goal setting

• Coordinates care and facilitates care plan• Coordinates care and facilitates care plan • Assure that all Veterans have info and

access to VA system/PACT and theaccess to VA system/PACT and the OEF/OIF/OND program

• Keeps all members of the Veteran’s teamKeeps all members of the Veteran s team on the same page

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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 d t d di t dneeds are met and care coordinated

• Understands resources and how to accessF ili l h d ff• Facilitates seamless handoffs

• Facilitates shared decision making• Assures that Veteran knows who is on the

team• Promotes health and well being reaching out

to nurture relationships 50

Patient Aligned Care TeamPatient Aligned Care Teamfor Returning Combat Veteransfor Returning Combat Veteransfor Returning Combat Veteransfor Returning Combat Veterans

Patient centered, team based, integrated careEvidence based continuously improving careEvidence based, continuously improving care

CommunicationCommunication

Combat Veteran Care/Case Manager

Collaboration Coordination

P t C b t C PACT f dPost-Combat Care moves our PACTs forwardThe PACTs move our Post-Combat Care forward 51

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)and preventive medications)

E d h lth li i d• Endorse healthy living messages and respond to questions from patients

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Support for RN Care Managers

• Training Programs and Support in• Training Programs and Support in Patient-Centered Communication– Patient Education: TEACH for Success– Motivational Interviewing

• Tools and Resources– Websites (www.prevention.va.gov)– Clinical staff reference tools– Patient tools– Patient tools– Documentation tools– MOVE! Weight Mgmt. Program – Facility HPDP Program Committee

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Clinical Staff Guide to Healthy Living MessagesMessages

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Clinical Staff Guide to Health Coaching

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Coming Attractions: Healthy Living MaterialsLiving Materials

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Nurse Informaticists:

ADPAC – Automated Data Processing Applications Coordinatorpp

CAC – Clinical Applications CoordinatorPI/IS Coordinator PerformancePI/IS Coordinator – Performance

Improvement/Information Systems CoordinatorCoordinator

BCMA Coordinator – Bar Code Ad i i t ti C di tAdministration Coordinator

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Nursing Informaticists

• Nursing Informatics integrates nursing science, computer andnursing science, computer and information science and cognitive science to manage communicatescience to manage, communicate and expand the data, information, k l d d i d f iknowledge and wisdom of nursing practice.

• ( ANA 2008) 58

Nurse Informaticists

“Computers are incredibly fast, accurate

and stupid. Human beings are incredibly p g yslow, inaccurate and brilliant. Together they are powerful beyond imagination.”y p y g

Albert Einstein

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Telehealth Nursing

• The use of information and communication technology to deliver health services, expertise and information over distance

• Constant with the principles of primary healthcarehealthcare

Di ti di i d• Disease prevention, diagnosis and treatment 60

Telehealth Nursing

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

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Other Roles to Consider

• Travel Nurse– OR– Pediatrics

Critical Care– Critical Care• Nurse Educator

MSN– MSN– PhD, DNP

• Nurse Administrator• Nurse Administrator– Nurse Manager– CNO

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