Programs and Communities

Background: Healthcare providers are encouraged to prepare their practice to effectively manage the care of mild to moderate adolescent depression. Cost-effective screening, diagnostic, and newly developed pediatric primary care depression management guidelines have been established. To integrate guidelines into practice, primary care providers (PCPs) must document effectively to ensure a complete treatment plan is in place in the patient’s electronic health record (EHR).

Intervention: Elements from a flowsheet were implemented into the EHR to promote thorough assessment and documentation of care delivered to adolescents with depression.

Methods: An initial chart review was completed on patients diagnosed with depression. An updated depression template was implemented within the EHR for six weeks. A follow-up chart review was completed post-intervention to determine if documentation of elements from the adolescent depression guidelines improved after the EHR update. Pre-intervention and post- intervention surveys were delivered to PCP’s to understand their perspective on adolescent depression management.

Outcomes: The chart review revealed that baseline PHQ-9 screenings were documented in 91% (n=43) of the charts reviewed in the pre-intervention timeframe. Only 78% (n=7) of the charts reviewed during post-intervention included PHQ-9 screenings. Early intervention treatment options documented in the pre-intervention timeframe included education 100% (n=47), medication prescriptions 53% (n=25), and psychotherapy referrals 18% (n=18). During post- intervention, education 100% (n=9), medication prescriptions 78% (7), and psychotherapy referrals 22% (n=7) were documented by the PCPs.

Recommendation: The quality improvement project focused heavily on documentation completed over a one year pre-intervention timeframe compared to a six-week post-intervention timeframe. Further evaluation and chart review over the next year will provide a more adequate comparison of documentation within primary care practice.

Disease burden is higher in the United States than in comparable countries. The Patient Self Determination Act of 1990 requires healthcare facilities to provide Advance Care Planning (ACP) information to all Medicare patients. The healthcare staffs’ (n=7) commitment to 3-days of ACP training increase ACP rates in the primary care setting. The Medicare Incentive Program is the platform for this initiative. This quantitative project used a valid and reliable pre and posttest design that consisted of 27 items on a Likert-scale. A 3.5-month chart audit (n=91) was conducted to assess the completion rate. Descriptive statistics was used to describe the demographic data.

The results of the two-tailed Wilcoxon signed rank test were significant based on an alpha value of 0.05, V = 0.00, z = -2.37, p = .018. There was a significant increase in the post-readiness to change average scores. A Mann Whitney test was used to analyze the statistically significant difference between the averages in two ACP types and electronic health record documentation (EHR). Staff did not always code (Mdn = 0.00) but they documented in the EHR (Mdn =1.00; 512.00, p = 0.003). ACP discussion was performed 63% of the time during Annual Wellness Visits (AWV), and there was a 49% increase in the EHR documentation. Trained staff are key stakeholders in guiding ACP conversations. They understand the barriers, impact, and consequences related to the lack of advance directives.

Professional nurse involvement in shaping the electronic health record continues to be minimal in spite of the presence of shared governance models. The redundancies and nurse dissatisfaction with the electronic health record requires a new approach. The advancement of a shared governance model to a professional governance model has resulted in an increase in professional role involvement in four areas:

1. Accountability.
2. Professional obligation.
3. Collateral relationships.
4. Decision-making.

Increased professional nurse involvement results in, nurses more actively engaged in problem solving to improve nurse satisfaction with the electronic health record. Evidence reflects a positive impact on nurse satisfaction when a professional shared governance structure is in place and guides the professional practice of nurses specific to autonomy and accountability. Additionally, evidence also revealed that nurses have a desire to be included in the quality of design, implementation and sustainability of electronic documentation.

The human papillomavirus (HPV) is the most commonly spread sexually transmitted infection in the United States. Although the HPV vaccine protects against transmission of the most common strains of HPV that cause genital warts and numerous urogenital cancers, uptake in the United States remains suboptimal. Failure to vaccinate leaves individuals vulnerable to the virus and subsequent complications of transmission. The evidence demonstrates that provider recommendation alone increases rates of vaccine uptake. The literature does not suggest a specific method for provider recommendation delivery; however, best practice alerts (BPAs) were correlated with increased vaccination rates.

These findings have directed a proposed project that includes an electronic health record (EHR) change prompting internal medicine, family practice and women’s health providers to educate and recommend the HPV vaccine at a Federally Qualified Health Center (FQHC) in the Southwest United States. The project demonstrates that after the implementation of a practice change of a HPV BPA in the EHR, HPV vaccination rates increased. Practice settings pre and post were similar, making the increase clinically significant.

The strengths of this project include an increase in HPV vaccination rates, a sustainable intervention, and an intervention that can easily be replicated into other health maintenance tasks. There were some limitations including the BPA alert only catching the HPV 9 vaccine series and the BPA did not always capturing historical data. Despite these technical barriers the HPV BPA delivered an increase in the HPV vaccine to protect more individuals from the HPV virus, increased provider adherence to national guidelines, and provides a platform for BPAs to be utilized for other vaccines.

As Baby Boomers age, the number of older homeless patients facing end of life is increasing. Homeless individuals die of the same diseases as their domiciled counterparts, but they have distinct barriers to equitable end-of-life care, such as lack of regular medical care, a higher likelihood of comorbid serious mental illness and substance abuse, alienation from potential healthcare proxies, and specific fears related to dying. Completion of an advance directive (AD) would address many of these barriers, as well as national goals of reducing medical costs associated with end of life care. A review of the literature indicates that homeless individuals, once educated on the purpose and significance of ADs, complete them at a higher rate than non-homeless people. Further, racial and ethnic disparities in document completion are minimized with educational interventions about an AD’s purpose.

King’s Theory of Goal Attainment provides the theoretical basis for the application of such an intervention in the setting of a medical respite center and a day resource center that both serve the homeless. Thirty-seven clients of the two sites and 14 staff members were administered a pre-and post-test measuring attitudes and knowledge relating to ADs on a Likert scale, resulting in an increase in knowledge about one of the two documents that traditionally comprise an AD, while not significantly affecting attitudes. Implications for practice include an inexpensive intervention that does not require a medically trained individual to deliver, enabling a broad application to a variety of settings with the goal of empowering a traditionally disenfranchised population to make health decisions related to the most vulnerable of life passages.