www.postersession.com

Innovation

The aging population and increasing healthcare costs, along with the shortage of primary care providers, has led to growing concern that current models of primary care will not be sustainable for meeting the needs of the American population. Cost-effective shifting of care from inpatient to the outpatient setting has led to increased complexity of care “outside of hospital walls.”

Aging population

Increasing healthcare cost o 1990 = $713 billion, 2010 = $ 2.6 trillion

Shortage of primary care providers

Chronic diseases o patients least able to navigate complex and fragmented health care system o ten % of patients used 70% of all healthcare dollars

Cost-effective shifting of care o inpatient to outpatient setting o access to care issues o coordination of services

Implementing the PCMH model ushers in newly defined roles for the healthcare team. At the center of this change is the RN, functioning at the highest level of his/her education. The ANA’s 2012 report, “The Value of Nursing Care Coordination,” highlights numerous studies showing the positive impact of care coordination by RN.

goal of containing cost uses evidence-based practice strategies decrease ED visits, hospital admission/readmissions lowers total annual Medicare costs improves patient satisfaction and self-manage care

Aims

Primary aim: implement/evaluate a care delivery model

integrating the RN Care Coordinator into the PCMH.

Focusing initially on population management of diabetes and

changes in diabetic quality indicators.

The quality indicators are based on the percentage of patients meeting the “D5” indicators: 1. Blood pressures less than 140/90 2. HgBA1C less than 7 3. LDL less than 100 4. Documented smoking cessation counseling (prn) 5. Prescribed aspirin with vascular disease.

Additionally, yearly document of: 1. Microalbuminurea level 2. Retinal examination 3. Filament foot examination

Secondary aim: Patient and healthcare team satisfaction and the fidelity of the RNCC role.

Transformation of Care:

Integrating the RN Care Coordinator into the Patient-Centered Medical Home

Pamela Biernacki, MSN, NP-C

DNP Student – Duke University

Results (preliminary)

References

Design A pretest-posttest design will be used to assess

quality indicators for the patient with DM, by using a paired

sample t-test for a comparison of the initial quality

indicators at 9 months post implementation. Additionally, a

descriptive survey post implementation will be used to

obtain patient and healthcare team satisfaction with the

role of the care coordinator.

Setting In a southeastern state, a family practice with

approximately 10,000 patients is part of a medical group

within a large health system consisting of multiple

hospitals, long-term care facilities, and outpatient facilities.

According to the 2012 census estimate, the practice serves

a small city with a population of 15,167 and surrounding

counties with a population of 68,967. Persons over the age

of 65 are 21.5% in the county, compared to 12.5% in the

state.

Sample The diabetic patient population is estimated at 950

persons. The electronic medical record (EMR) and the

Diabetic Registry (DR) will be used to produce a list of

patients at the start of the innovation, based on the

inclusion and exclusion criteria. The inclusion criteria

consist of a diagnosis of DM with documentation of fasting

blood glucose (FBG) of greater than 126 on two different

dates, and age between 18 and 75 years. The exclusion

criteria include: patients followed by an endocrinologist

more frequently than two visits within the last year. The

patient satisfaction survey will be sent to this patient

population with access to MyChart, the health system

email. The healthcare team sample for the satisfaction

survey will include all providers and clinical staff that are

employed at least part-time at the start of the innovation.

This sample currently includes three MDs, three NPs, one

PA, one OM, five AAs, two RNCCs, four LPNs, and three

MAs.

Agency for Healthcare Research and Quality. (2012). Retrieved from

http://www.ahrq.gov/clinic/tp/gappcmhtp.htm

American Academy Ambulatory Care Nursing. (2011). Retrieved from http://www.aaacn.org

American Academy of Nursing. (2012). Raise the voice: Transforming America's health care

system through nursing solutions. Retrieved from http://www.aannet.org/raisethevoice

American Nurses Association. (2012). Position statement: Care Coordination and Nurses’

Essential Role. Retrieved at http://nursingworld.org/MainMenuCategories/Policy-

Advocacy/Positions-and-Resolutions/Issue-Briefs/Care-Coordination

Anderson, D. R., St. Hilaire, D., & Flinter, M. (2012). Primary Care Nursing Role and Care

Coordination: An Observational Study of Nursing Work in a Community Health Center.

Online Journal of Issues in Nursing, 17(2), 1. doi:10.3912/OJIN.Vol17No02Man03

Institute of Medicine. (2011). The Future of Nursing: Leading Change, Advancing Health. Washington

DC: The National Academies Press.

Mastal, M., & Levine, J. (2012). Perspectives in Ambulatory Care. The Value of Registered

Nurses in Ambulatory Care Settings: A Survey. Nursing Economic$, 30(5), 295-304.

Moran, K., Burson, R., Critchett, J., & Olla, P. (2011). Exploring the cost and clinical outcomes

of integrating the registered nurse-certified diabetes educator into the patient-centered

medical home. Diabetes Educator, 37(6), 780-793.

Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The care

span: The importance of transitional care in achieving health reform. Health Affairs,

30(4), 746-754.

Vinson, M. H., McCallum, R., Thornlow, D. K., & Champagne, M. T. (2011). Design,

Implementation, and Evaluation of Population-Specific Telehealth Nursing Services.

Nursing Economic$, 29(5), 265-277.

RNCC project will also include: Population management Telehealth follow-up Standardized patient education Self-management skills Group education visits Pre-planning with daily huddles Monthly PMCH meeting

Introduction

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

Diabetic Patient Quality Indicators (striving for perfection)

Patient Appointments No HgBA1C Over 7 Over 8 Foot Exam Eye Exam

Innovation

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Pe

rce

nt

Diabetic Patient Quality Indicators (striving for perfection)

Patient Appointments No HgBA1C Over 7 Over 8 Foot Exam Eye Exam

Methods

TM