PUBLIC HEALTH AND PRIMARY CARE INTEGRATION: A PARTNERSHIP TO ADDRESS POPULATION HEALTH
Tiana Wyrick, RN, BSN; Renee Wing, RD; Kristine Pelerin, BS, CPHQ; and Margaret Casey, RN, MPH
Background: High blood pressure (BP) or hypertension is a leading risk factor for heart disease and stroke, leading causes of death in the U.S. Self-measured blood pressure (SMBP) combined with clinical support is effective in controlling hypertension, improving patient knowledge and engagement, and increasing medication adherence.
Problem Statement: A barrier to health systems in referring low income patients to SMBP is the out-of-pocket cost passed on to patients to purchase a BP monitor.
Project Description: Through a grant from CDC, the New York State Department of Health (NYSDOH) designed and implemented a BP monitor loaner program across 65 Federally Qualified Health Centers (FQHCs). NYSDOH provided FQHCs with support in: adopting standardized hypertension measures to create registries to identify patients with uncontrolled hypertension; creating electronic health record templates and clinical workflows to support practice teams in engaging patients and documenting SMBP referrals; obtaining validated BP monitors; and facilitating technical assistance using a guide titled SMBP: Engaging Patients in Self-Measurement.
Evaluation and outcomes: The program was evaluated at 7 sites as part of a learning collaborative. Between January and June 2018, the collaborative: o Enrolled 440 patients in a BP monitor loaner program; o Improved BP control by 5%. • One FQHC evaluated a cohort of 139 patients who completed the program using an individual 6-month pre- and post-assessment of quality metrics with the following results: 78% lowered their BP; 20% increase in adherence to follow-up visits; o 42% decrease in Emergency Department visits; 21% decrease in in-patient stays.
Conclusions: A BP monitor loaner program has demonstrated effectiveness in controlling hypertension, increasing medication adherence, and improving patient engagement.
Implications for practice: Public health and primary care integration can be a powerful partnership in overcoming the barriers to addressing population health needs in improving hypertension management and control.
INFLAMMATION MAY CONTRIBUTE TO DEPRESSIVE SYMPTOMS AMONG HYPERTENSIVE INDIVIDUALS
Dillon J. Dzikowicz, BS, RN, PhD
Introduction: Inflammation has been attributed to both depressive symptoms (DS) and hypertension (HTN). Interleukin-6 (IL-6) has been associated with both conditions. Antihypertensive medications may affect levels of IL-6, and possibly DS.
Specific Objective: The objective of this analysis was to assess the effect of HTN on DS mediated by IL-6 among individuals with HTN, and assess the effect of antihypertensives on IL-6.
Methods: Data was from the 2016 wave of the Midlife in the United States (MIDUS) study which collected data from a sample of adults in the United States. In this analysis, individuals with >pre-HTN (>120/ >80 mmHg) were included. DS was measured using the Center for Epidemiological Studies Depression (CESD) (range 0-60, higher score=greater symptomatology). Path analysis adjusted for antihypertensives, age, and sex was conducted to assess relations between HTN, IL-6, and DS. The effect of HTN medication types on IL-6 was assessed using linear regression adjusted for age and gender.
Results: Five-hundred forty-two individuals were included (mean age=52.9+13.1 years; 56.0% male; mean CESD=9.28+7.91; mean IL-6=3.08+2.5). Most individuals had Stage I HTN (49%), and 43% of individuals were on HTN medications mostly thiazide diuretic (36%). The total effect of HTN on DS was statistically significant (B=1.6286; p=0.0005; 95%CI 0.7140-2.5432; R2=0.0857); and, the direct effect of HTN on DS was as well (B=1.2569; p=0.0072; 95%CI 0.3423-2.1714; R2=0.1176). IL-6 was a partial mediator of DS (B=0.3717; p=0.0024; 95%CI 0.1616-0.6410). Antihypertensives were associated with reduced levels of IL-6 (B=-0.5824; p=0.0086; 95%CI -1.0161- -0.1487; R2=0.0849). Thiazide diuretics demonstrated the strongest negative association on IL-6 among all antihypertensives (B=-0.552; p=0.049; 95%CI -1.1162- -0.0011).
Conclusions: Among middle-aged adults with HTN, inflammation may partially mediate DS. Thiazide diuretics may reduce IL-6 inflammation. Implications: Inflammation may contribute to DS among middle-aged adults with HTN. Thiazide diuretics may reduce IL-6 levels, and be associated with reduced DS.
OUTCOMES MEASURES IN CARDIOPULMONARY REHABILITATION: HOW ONE PROGRAM MEASURES UP
Susan Boyle, BSN, RN; Michael Lippmann, MD; Theresa Gordon, BSN, RN; Tiffany Schultheis, BSN, RN; and Lauren McMillan, PT
We sought to identify meaningful ways patients could benefit from an 8-week outpatient or 5-week inpatient cardiopulmonary rehabilitation program. We compiled 5 years of data to evaluate program completion rates, evidence-based outcomes and patient satisfaction ratings. We administered the Six Minute Walk Test and the Rand 36-Item Health Survey to patients at the beginning and end of the program in order to measure change in exercise capacity and health-related quality of life perceptions. The Six Minute Walk Test demonstrates excellent reliability and validity and bears a strong relationship to important clinical outcomes. The distance which the patient walked in 6 minutes had a direct correlation to formal measures of quality of life; the greater the distance, the better the quality of life scores. The Rand 36-Item Health Survey is among the most widely used health status measures in use. The 36 question survey (8 subcategories) allows the patient to rate his/her health in a general sense. 342 outpatients (74%) and 168 inpatients (81%) completed the program. 204 out of 308 outpatients (66%) and 109 out of 147 inpatients (74%) demonstrated improvement in exercise capacity on the Six Minute Walk Test. 246 out of 319 outpatients (77%) and 149 out of 164 inpatients (90%) demonstrated improvement in health-related quality of life. Outpatients consistently scored highest in 3 subcategories: General Health, Physical Function and Energy/Fatigue. Inpatients consistently scored highest in 5 of the subcategories. 96 to 100% of outpatients and 93 to 100% of inpatients rated their overall program satisfaction as very good to excellent. We concluded that patients in the cardiopulmonary rehabilitation setting can derive significant health benefits from program participation. Nurses are positioned to make a critical difference in the lives of patients who rely on our expertise to make positive lifestyle changes and improve quality of life.
TO CALL OR NOT TO CALL: ASSESSING THE IMPACT OF NURSE POST-DISCHARGE TELEPHONE CALLS ON 30 DAY HOSPITAL READMISSION RATES
Cherie Parks, BSN-BC; Melly Turner, BSN, RN-BC, FPCNA; Kathie Ward, DNP, RN, PHCNS-BC; Felicia Murphy, MSN, RN-BC; Peggy Dame, BSN, RN-BC; Kelli Hale, BSN, RN-BC; Jenny Dixon, MSN, RN-BC; Marian Lawson, BSN, RN-BC; Anita Barber, BS; and Dayna Monaghan, BSc
Introduction/Background: In an effort to reduce hospital readmission rates nationwide, the Centers for Medicare and Medicaid Services (CMS) in 2012 began financially penalizing hospitals with higher than expected readmission rates. According to data from 7/1/2014-6/30/2017, national cardiology readmission rates vary based on service, ranging from 10.2 to 21.7%. Vizient database reveals, the national rate for cardiology service line is 12% and University of Virginia’s rate is 14%.
Goal: The primary outcome was to determine if receiving a post-discharge telephone call would decrease 30-day readmission in an acute cardiology services population.
Method: Patients received one telephone call attempt by a nurse within 24-72 hours of discharge to home. Nurses followed a standard script to check on symptoms, review medications and treatment plans, and remind patients of follow-up appointments. Calls were documented using a note template in the electronic medical record (EMR). Patients who did not answer, but had a voice mail were left a message. Some patients did not have voice messaging. Some patients were missed and did not receive a call attempt. All call attempts were documented using standard phrase in the EMR.
Results: 536 patients were discharged home from the acute cardiology service July through October 2018. The total readmission rate was 12.5%. RN staff called and spoke to 61.2% of discharged patients. Of those contacted patients and had no nursing interventions, 12% were readmitted within 30 days. RN staff did not speak to 38.8% of discharged patients of which 15.8% were readmitted.
Conclusion: In this exploratory study, discharge calls in which the patient was contacted by a cardiology RN to review symptoms, medications and follow up plan did reduce all cause readmission rate by 10.6% compared to those who were not able to have this conversation.
Discussion/Implications: The Heart and Vascular Center service lines needs to continue to explore multiple avenues to decrease readmission rates.
HEART FAILURE TRANSITIONS PROGRAM
Barbara Hinch, DNP, ACNP-BC
Introduction: In the US, the 30-day readmission rate is largely variable across hospitals with estimates ranging 10-50%. It is predicted that up to 75% of these readmissions may be preventable with improved transitional care services. A Midwest Academic Medical Center was not at their predicted rate of readmission for heart failure (HF). We describe the development of a quality improvement initiative to address gaps in the continuum of care.
Methods: The Heart Failure Transition Program (HFTP) is an integrated, interdisciplinary team that utilizes care management, home health agencies (HH), social work outreach (Bridge SW), daily phone and email communication. These systematic strategies for communication amongst the team allow for follow up ensuring patients appropriate follow up. Monthly analysis of possible missed opportunities to prevent readmissions was evaluated. Intensive front loading of services during the first week post discharge is unique in this model: 24-hour medication reconciliation, home health visits, transitional care management call (TCM), Bridge social worker call, and aggressive screening for barriers to care.
Results: The HFTP reduced readmission rates compared to the previous reported annual rate of 24.5% in FY2016. At termination of the 11-month program, the cumulative readmission rate was 18.22% (n= 82/450). The primary reason for readmission included HF (n=47, 57.32%) and non-HF indications (n=35, 42.68%); 90% of patients left with HF clinic appointment in 7-10 days however only 40% attended appointment.
Patient data: average age 64.5 years, 90% HTN, 50% have CAD, CKD or DM; 65% are Medicare/Medicaid, 27% private insurance and 8% uninsured; 50% of patients were discharged without home health (HH), 40% went home with HH. Program process outcomes include: 93% received inpatient psychosocial evaluation; 91% received follow up TCM call within 72 hours and 78% received Bridge social worker follow up call within 1 week post discharge.
Conclusion: The HFTP connects inpatient care to the post-acute care ambulatory and community setting which is unique in this model. Based on data, this model is effective for care coordination to help achieve the hospitals overall HF goals.
NURSE DISCHARGE READINESS ASSESSMENT: A STRATEGY FOR PREDICTING AND REDUCING READMISSIONS
Arlene Travis, ANP-BC, CHC, CHFN-K; Marianne Weiss, DNSc, RN; and Kathleen Bobay, PhD, RN, NEA-BC
Excessive readmissions can result in reduced reimbursements for hospitals. Inadequate discharge preparation and poor care transitions are associated with increased risk of readmission. Initiatives to improve transitions have largely ignored clinical nurses, even though they have primary responsibility for preparing patients for discharge. Observational research indicates that nurses can accurately identify patients with low readiness for discharge. These patients have 6-9x increased risk of readmission. Our hospital was one of 33 Magnet hospitals participating in the ANCC-sponsored “READI” Study (Readiness Evaluations and Discharge Interventions), a randomized-controlled trial testing the effect on 30-day readmissions/ED visits of implementing nurse discharge-readiness assessment as standard nursing practice on a hospital unit. One unit at our hospital (cardiothoracic surgery) was randomized to implementation; another unit to control. All implementation unit nurses performed discharge-readiness assessments using the Readiness for Hospital Discharge Scale, an 8-item (range 1-10) validated instrument. Three increasing levels of assessment were implemented: 1) Nurse discharge-readiness assessment; 2) Nurse assessment informed by patient self-assessment; 3) Nurse+patient assessment, with requirement to act on low readiness. Our total sample=4800 discharges (Implementation and Control). Implementation unit nurses performed 1,344 discharge-readiness assessments over 12-months, demonstrating high fidelity (>80% of eligible patients assessed). All other data (outcome and control) came from EMR and NDNQI data. 12.8% of patients were identified as low-readiness. RN assessments strongly correlated with patient self-assessment (r=.69; p<.05.) Low readiness predicted readmissions and ED visits. Each 1-point decrease in RN-rated readiness was associated with 5.6% increase in readmissions (p<.05); each 1-point decrease in patient-assessed readiness with a 7.6% increase (p<.05) in ED visits. A multi-site analysis indicated a significant treatment effect on readmission rates and ED-visits. The study identifies how nursing practice can improve patient outcomes and generate value by preventing revenue loss. Clinical nurses can successfully perform well-designed nursing research in the clinical care setting.
IMPLEMENTATION OF A HEART-FAILURE DEPRESSION PROTOCOL
Susan A. Davis, DNP
Approximately 30% or more of hospitalized heart failure (HF) patients have depression, a fifth of HF patients have an undiagnosed depression diagnosis, and a third of diagnosed depressed HF patients have significant depression symptoms when admitted. Poorer HF outcomes are associated with HF patients having depression symptoms, especially after hospital discharge. The recommendations to screen and to treat depression in admitted HF patients have been identified, but no protocol is given in the practice guidelines. Barely any evidence exists, related to the development of an inpatient HF depression screening protocol, and it being implemented. Purpose/ Methods: As part of a quality improvement project, a HF-depression protocol was developed and implemented for 6 weeks by registered nurses (RNs) on two cardiac progressive care units (PCU) at a medical clinic located in Southwestern, Virginia. In the protocol, RNs used the PHQ-9 depression screening tool to identify the depression severity for each HF patient, and to determine and or initiate the appropriate depression treatment prior to discharge and depression symptom follow-up. This project aims to measure the feasibility of an inpatient HF- depression protocol’s implementation by RNs, and its selected depression screening tool, (b) to evaluate nurse’s perceptions on the acceptance and adequacy of support in implementing a new HF- depression protocol, and (c) assess for correlations between the HF patient’s descriptive characteristics, ejection fraction, the patient having a prior to admission depression diagnosis, and or taking a medication for depression and their overall PHQ-9 severity score. Results: A sum of 47 HF patients were admitted to the PCUs; 70% (n=33) had depressive scores above 5 on the PHQ-9, 25.54% (n=13) required intervention and 65.96% (n=33) required depression follow-up. Three-fourths (35) of 47 HF patients had no prior to admission depression diagnosis but were experiencing significant depressive symptoms. Depression mean scores for men were higher, especially for the Caucasian men. Surveys from 17 RNs indicated: 94.11% had received adequate preparatory education, with 93.75% finding the protocol was easy to follow and 94.12% indicated the PHQ-9 was easy to use. Two-thirds (67.58%) of RNs perceived the providers supported the protocol during implementation and 76.47% felt it was supported by administration. Discussion/ Conclusions: Findings indicated the protocol can be used efficiently by RNs and it is effective at identifying HF patients needing depression interventions, a psychiatric referral, and or post-discharge depression symptom follow-up.
INFLUENCING FACTORS OF PATIENTS KNOWLEDGE REGARDING ANTICOAGULANTS AND HEALTH BELIEFS AMONG PATIENTS WITH ATRIAL FIBRILLATION RECEIVING ORAL ANTICOAGULANTS
Yu-Hsia Tsai, RN, PhD; Meei-Fang Lou, RN, PhD; Chi-Tai Kuo, MD; Her-Kun Chang, PhD; Kuo-Liong Chien, MD, PhD; Bih-Shya Gau, RN, PhD; and Lai-Chu See, PhD
Understanding factors that influence patients’ knowledge and health beliefs regarding oral anticoagulants (OACs) could provide effective medication instruction. Purpose: This study examined patients with atrial fibrillation (AFib) taking OACs to determine the factors influencing their knowledge regarding OACs and their health beliefs. Methodology: A randomized controlled study was conducted. The participants had been diagnosed with AFib and were receiving OACs. They were randomly assigned to the experimental or control group. The research instruments were medication knowledge, health beliefs and satisfaction. Measurements were taken pretest and after 3 months. The intervention administered to the experimental group was a one-to-one interactive instruction regarding Health Belief Model–driven strategies and health information technology systems. Patients in the control group received brochures. Factors related to the effectiveness of these approaches were analyzed using multiple linear regression. Results: A total of 159 participants were recruited (experimental group=79, control group=80). Improvements in total scores for knowledge and health belief were positively correlated (r=0.58, p<0.001). Predictors for improvement in knowledge included being in the experimental group (B=5.87), taking non-vitamin K antagonist OACs (B=3.37), having a lower perceived severity (B=−0.08), having lower self-efficacy (B=−0.06) and having higher medication satisfaction (B=−0.05) in the pretest. The total explained variance was 58.4%. The predictors for improvement in health belief were having lower pretest scores in medication knowledge (B=−0.68) and being in the experimental group (B=6.63). The total explained variance was 14.3%. Conclusions and implications: Health care providers should provide health education based on theoretical strategies and through multiple methods. To advance medication-related knowledge among patients, providers should focus on the different needs of patients, increasing theACs. Promoting patients’ medication knowledge could also improve their health beliefs.