J i H J il M id Jeri Hargrave, Janquilyn Merida, Michele Owens

Nursing 6035: DNP Practicum INursing 6035: DNP Practicum IOctober 19, 2009

Is a system a clinical decision making Is a system, a clinical decision-making process, a technology, a role, and a service.

A process of determining integrating and A process of determining, integrating, and monitoring complex client needs.

Seeks to balance quality of care outcomes Seeks to balance quality of care outcomes with efficient use of existing resources.

Specific characteristics of case management Specific characteristics of case management include•Emphasis on active client participation•Emphasis on active client participation•Holistic orientation•A self-care, self-deterministic orientationA self care, self deterministic orientation•Coordination and efficient use of a wide range of

human services

Represents a vulnerable population Represents a vulnerable population Faces specific health care challenges

•Access to care•Access to care•Scarce resources•Traditional cultural belief systemsTraditional cultural belief systems

Rural case managers need to be ‘generalists’ Rural case managers need to be generalists Framework for nursing case management

includes five dimensions: includes five dimensions: •Assessment•PlanningPlanning•Implementation•Evaluation•Interaction

ClinicalClinical

Financial

Functional well-being

S fSatisfaction

QualityQ y

Humanistic

Goal: To provide a continuum of services Goal: To provide a continuum of services designed specifically to meet a client’s needs for a specific period of timefor a specific period of time.•Availability

•Affordability

•Acceptability•Acceptability

The Veterans Health Administration (VHA) The Veterans Health Administration (VHA) mandated a 200% increase in midlevel providers in response to healthcare over the providers in response to healthcare over the past decade to expand access to care.

Approximately 30% of VHA primary care Approximately 30% of VHA primary care providers are midlevels.

2009 study at VA examined whether 2009 study at VA examined whether treatment change for diabetic patients presenting with elevated BP differed presenting with elevated BP differed between physicians and midlevel providers.•(Subramanian et al 2009)•(Subramanian et al., 2009)

Hospital at home care for COPD Hospital-at home care for COPD exacerbations: an observational cohort study of patients managed in hospital or NPs in the of patients managed in hospital or NPs in the community.•(Ansari Shamssain Farrow & Keaney 2009)•(Ansari, Shamssain, Farrow, & Keaney, 2009)

National study sought information from rural National study sought information from rural patients•1 to assess the prevalence of health seeking outside •1. to assess the prevalence of health seeking outside

of community•2. examine impact of locally available PCPs and p y

hospital size on bypass odds•3. identify patient demographic and geographic

factors

32% of respondents bypassed local primary 32% of respondents bypassed local primary care.

Conclusion: Strategies to reduce bypass Conclusion: Strategies to reduce bypass behavior should be directed at the local community or facility levelcommunity or facility level.•(Liu, Bellamy, Barnet, & Weng, 2008)

1 Interprofessional collaboration has 1. Interprofessional collaboration has repeatedly been shown to decrease healthcare costs and improve both care healthcare costs and improve both care quality and health outcomes.

2 DNP graduates in clinician roles engage in 2. DNP graduates in clinician roles engage in balancing acts daily when collaborating with other healthcare professionalsother healthcare professionals.

3 Knowledge of effective collaborative 3. Knowledge of effective collaborative communication between healthcare disciplines will enable DNP graduates to disciplines will enable DNP graduates to effectively build a bridge between healthcare disciplinesdisciplines.•(Chism, 2010)

P T is a 63 year old white femaleP.T. is a 63 year old, white female•DX – Insulin dependent diabetes mellitus, s/p cva in

20032003•PMH – Former smoker 1/pk/day for 20 years, quit

2003; does not drink alcohol or use illicit drugs•SH – worked for American Airlines until stroke, has a

disabled son that lives with her, and a male companioncompanion.

•Allergies - none

Recent medical problems: Recent medical problems:• Fell in spring 2009 and broke an endplate at L4. • Has used a walker or cane since stroke. • Since fall relying mostly on walker. • Spending more time in bed.• Cut bottom of foot• Cut bottom of foot.

Interdisciplinary Care:• Home health: skilled nurse, occupational therapy, physical

therapy.• Provider: monitor, cleanse, and dress foot wound. Monitor labs.

M S is a 57 year old white maleM.S. is a 57 year old, white male•Social History- Divorced. Smokes < 1 PPD times 30

years No ETOHyears. No ETOH.•Allergies- Nuts, Sunflower seeds, Pecans, Bee stings,

PCN, Glucophage, Velosef

•Past Medical History- Depression (history of Past Medical History Depression (history of molestation at 12 years), Type 2 DM (Insulin), HTN, Severe OSA,

•Klinefelter Syndrome (XXY) Very long arms and legs, large hands and feet

Testosterone deficienc Testosterone deficiency (Lewis, 2008)

Interdisciplinary Care Interdisciplinary Care•Podiatrist (Diabetic foot ulcer)•Surgeon (Recent skin graft)•Surgeon (Recent skin graft)•Urologist (Erectile Issues; Potential Penile Implant)•DADs service through Girling Home Health g g Provider, nursing care of ulcer by wound vacuum, and

dietician

R t L b (9/30/09)Recent Labs (9/30/09)•Fasting glucose-192, HA1C-8.4 decreased from 9.1,

normal renal and lytesnormal renal and lytes

THE DNP WORKS THE DNP EMPLOYSTHE DNP WORKS THE DNP EMPLOYS

independently and collaboratively

evidence-based practices various information systems and collaboratively

• In order to aggressively manage the complex, rural underserved population

various information systems quality patient care evaluate outcomes

underserved population

Chronically ill patients account for more than 125 Chronically ill patients account for more than 125 million Americans.

Reported better disease control with case management and thus improved quality of life for the patient.

Case Management with oversight by nurse practitioners is cost effectiveis cost effective.

Patients Caregivers Caregivers Clinical and Medical staff Third party payors

St k h ldStakeholders

There is a body of research and practical There is a body of research and practical experiences that support the superior quality and cost benefits possible through case and cost benefits possible through case management of the complex rural underserved population by the DNPunderserved population by the DNP.

Telemedicine includes care that is provided Telemedicine includes care that is provided despite the distance.

Telemedicine has an emphasis on patients’ Telemedicine has an emphasis on patients long-term wellness as well as current chronic illnessillness.

DNP collaboration may be improved through telemedicine by providing consultation in telemedicine by providing consultation in rural areas where care otherwise would not be givenbe given.

The DNP often uses the knowledge garnered The DNP often uses the knowledge garnered through the DNP program• to integrate evidence based practice • to integrate evidence-based practice, •utilize information technologies,•to build a bridge between the disciplines in order to to build a bridge between the disciplines in order to

successfully manage the rural underserved population.

Ansari, K., Shamssain, M., Farrow, M., & Keaney, N. P. (2009). Hospital-at-home , , , , , , y, ( ) pcare for exacerbations of chronic obstructive pulmonary disease: An observational cohort study of patients managed in hospital or by nurse practitioners in the community. Chronic Respiratory Disease, 6, 69-74.

Brown S A & Grimes D E (1995) A meta analysis of nurse practitioners and nurse Brown S. A. & Grimes, D.E. (1995). A meta-analysis of nurse practitioners and nurse midwives in primary care. Nursing Research, 44,332–338.

Bushy, A. (2003). Case management: Considerations for working with diverse rural client systems. Lippincott’s Case Management, 8(5), 214-223.

Chism, L. A. (2010). The DNP graduate as expert clinician. In The doctor of nursing practice: A guidebook for role development and professional issues (pp. 63-105). Sudbury, MA: Jones and Bartlett.

Ettner S L Kotlerman J Afifi A Vazirani S Hays R D & et al (2006) Reducing Ettner, S.L., Kotlerman, J., Afifi, A., Vazirani, S., Hays, R.D.& et al. (2006). Reducing the costs of patient care? A controlled trial of the multi-disciplinary doctor-nurse practitioner (MDNP) model. Medical Decision Making, 26 (1), 9-17.

Friedman, M.M., Bowden, V.R., & Jones, E.G. (2003). Family nursing: Research, theory, and practice (5th ed). New Jersey: Prentice Hall.

Knudtson, N. (2005). Patient satisfaction with nurse practitioner service in a rural setting. Journal of American Academy Nurse Practitioners, 12 (10), 405-4 .

Lewis, R. (2008). Human genetics: Concepts and applications (8th ed.). Boston: McGraw Hill.

Liu J Bellamy G Barnet B & Weng S (2008) Bypass of local primary care in Liu, J., Bellamy, G., Barnet, B., & Weng, S. (2008). Bypass of local primary care in rural counties: Effect of patient and community characteristics. Annals of Family Medicine, 6(2), 124-130.

Mundinger, M.O., Kane, R.L., Lenz, E.R., Totten, A.M.., Tsai, W., et al. (2000). Primary care outcomes in patients treated by nurse practitioners of physicians: randomized trial. Journal of Medical Association, 283 (1), 59-68.

Salkever, D.S., Skinner, E. A., Steinwachs, D. M. & Katz, H. S. (1982). Efficiency comparisons of physicians and nurse practitioners Medical Care 20 146–154comparisons of physicians and nurse practitioners. Medical Care, 20,146 154.

Sherwood, G, Brown, M, Fay, V. & Wardell D. (2001). Defining Nurse Practitioner Scope of Practice: Expanding Primary Care Services. Journal of Advance Nursing Practice. Retrieved on October 14, 2009 fromhttp://www.anes.sagamed.ac.jp/ispub/journals/ijanp.htm.

Stanton, M.P., & Packa, D. (2001). Nursing case management: A rural practice model. Lippincott’s Case Management, 6(2), 96-103.

Subramanian, U., Kerr, E. A., Klamerus, M. L., Zikmund-Fisher, B. J., Holleman, R. G., & Hofer, T. P. (2009). Treatment decisions for complex patients: Differences between primary care physicians and midlevel providers The American Journal between primary care physicians and midlevel providers. The American Journal of Managed Care, 15(6), 373-380.