Doctor of Nursing Practice (DNP) Final Projects
The Doctor of Nursing Practice Final Projects collection contains the completed works of students from the DNP Program at Arizona State University's College of Nursing and Health Innovation. These projects are the culminating product of the curricula and demonstrate clinical scholarship.
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- All Subjects: Transitional Care
Ineffective transitional care programs for ensuring the continuation of care from acute settings to the home settings post discharge can result in rehospitalization of elderly patients with chronic diseases. Usually, transitional care should be time-sensitive, patient-centered services intended to ensure continuity of care and an efficient transition between health care settings or home. A patient centered transitional care program was implemented at an outpatient primary care facility to reduce readmission rates. Institutional Review Board approval was obtained.
Twenty adult patients with chronic diseases discharged from an acute setting were identified. A follow up phone call and/or a home visit within 24-72 hours post discharge was employed. The Care Transitions Measure (CTM®) and Medication Discrepancy Tool (MDT®) were utilized to identify quality of care of transition and medication discrepancies. A chart audit collected data on the age of participant, diagnosis for initial hospitalization, CTM score, home visit, and ED visits or re-hospitalizations after 30 days of discharge. The outcome indicated that transitional care within primary care utilizing evidence-based practices is beneficial in reducing readmission rates. A logistic regression showed model significance, p = .002, suggesting that the CTM score was effective for both telephone support (TS) and home visit (HV).
A correlation analysis showed that as age of participants increased, the CTM score decreased, indicating that older adults required more support. A significance p <.001, of a proportional test indicated that readmission rates after the intervention was lower. It is evident that providing a timely and effective transitional care intervention in a primary care setting can reduce hospital readmissions, improve symptom management and quality of life of adult patients with chronic diseases.
Background and Purpose: Readmission rates for those with chronic conditions are exceeding benchmarks and driving up healthcare spending; there is a need to improve care coordination and outcomes. This project was done to evaluate and offer evidence-based suggestions for improvement to a multidisciplinary care coordination team in an Accountable Care Organization (ACO). Internal data suggests the team is underutilized within the ACO and that the ACO is underperforming. Conscious workflow design has been shown to improve the efficiency of existing work processes.
Methods: The care coordination team (N=6), licensed practical nurses and social workers, were the project participants. Following Institutional Review Board approval, a presentation was given on current ACO performance data and project goals. Team members were invited to participate by filling out a survey. The 31-item Team Development Measure (Cronbach’s α) assessed team functioning to identify where gaps exist in the team’s processes. Further knowledge about workflow was gained via quality improvement methods of direct observation and informal conversational interviews with team members, the ACO team manager, and various providers within the ACO and their staff. Field notes were analyzed and confirmed with the ACO team manager. Rasch analysis was performed on survey data to convert ordinal numeric results from the Likert scale into an interval score from 0 to 100, which correlates with elements of team development.
Results: Rasch analysis revealed a mean score of 54.17 (SD=8.06). Based on this score, the team has cohesiveness and communication in place but has not yet established role and goal clarity. Analysis of notes and impressions revealed a lack of adherence to date deadlines, inconsistent processes among team members, and use of non-evidence based patient care interventions such as minimal to no home visits and a lack of standardized patient education. Team analysis results, workflow observations, and current evidence on transitional care were integrated into an executive report containing realistic prioritized changes that maximize team member’s skill sets and clarify roles and goals of the team which was provided to the ACO administration along with recommendations for evidence-based process improvements.
Conclusion: This project can serve as a model for analyzing team functioning and workflow to inform agencies where gaps in their processes are affecting performance. The analysis can then be used to recommend evidence based practice changes. Implementation of the suggested workflow should improve existing efforts in trying to meet benchmark quality measures for the ACO as well as improve team functioning.
Advanced Practice Registered Nurse Led Transitional Care Program in an Accountable Care Organization
Background: Hospital readmissions place a heavy financial burden on patients, families, and health care systems. Readmissions can be reduced or prevented by providing a safe transition through care coordination and enhanced communication. Research demonstrates implementation of APRN led home visits (HV) along with telephonic follow-up are cost effective and can be utilized for reducing readmissions among HF patients.
Methods: A program was designed with an ACO and carried out in a family practice clinic with a group of seven HF patients older than 50 years who were at risk of readmission. Interventions included weekly HV with supplemental telephonic calls by the APRN student along with a physician assistant for 12 weeks. Readmission data was collected. QOL and SCB were measured using “Minnesota Living with Heart Failure Questionnaire” (MLHFQ) and “European Heart Failure Self-Care Behavior Scale” respectively. Data was analyzed using descriptive statistics and the Friedman Test.
Outcomes: There were no hospital readmissions at 30 days and the interventions demonstrated a positive effect on QOL, self-care management and satisfaction (χ2 = 30.35, p=.000). The intervention had a large effect on the outcome variables resulting in an increase in QOL and SCB scores post-intervention (ES= -1.4 and -2 respectively).
Conclusions: TCP designed with an ACO, carried out in a primary care setting has a positive effect on reducing hospital readmissions and improving QOL, SCBs, and patient satisfaction among HF patients. TCPs are not revenue generating at outset due to reimbursement issues, however future considerations of a multidisciplinary team approach with convenient workflow may be explored for long-term feasibility and sustainability.
Funding Source: American Association of Colleges of Nursing and the Centers for Disease Control and Prevention with support of the Academic Partners to Improve Health.