Clincal Nurse Leader in the Community

1. Clincal Nurse Leader in the Community Pamela N. Clarke Fay W. Whitney School of Nursing University of Wyoming

2. National Need for Clinical Leadership • DNP or MS/CHN • Few CHN programs • Jobs have disappeared • Public needs health counseling to achieve cost efficient care • Nursing is natural fit [vs physicians, trained counselors or social workers] • Families need guidance negotiating the system and information (integration of care)

3. Clinical Nurse Leader in the Community • Masters prepared provider • Family focused • Fits model of care proposed in the state and AACN CNL competencies • AACN competencies critical to the model • Generalist vs Advanced Practice • Educator • Integration of care • Advocate • Population competencies

4. Unique Rural Environment • Access and transportation issues in frontier state • High-end specialty care out of state • Negotiation of complex care systems across state lines • Care coordination is critical • PHNs • Working in under-funded health departments

5. New Service Model • Public-Private partnership • Builds on PharmAssist Program (direct service to individual for medication regimen) • Clinical prevention [key element] • Timing coincided with national Clinical Nurse Leader movement • Need for data to support entrepreneurial venture: Efficient and effective

6. HealthAssist Business Model • Non-profit business: developed with assistance from Business and Law Schools • Long-term plan includes “for profit” venture • Initial funding from the state [5 state agencies] • Pilot project targeted toward high users of medications & services

7. OtherCommunity Programs DFS State Agencies State Programs DOE ExecutiveLeadershipTeam Health Assist WDH PowerfulFamilies WHINIDB Risk Analysis DOC WHIN Project Coordinator FamilyPerson DWS Health Services Family Success PilotChanging Delivery Systems Program-centric to Family-centric

8. Home Visit as the Core • Conceptual shift: patient-centered vs family-centered • Home-based services • Prevention and health promotion for all families • Family empowerment • Family advocacy and negotiation skills • Development of family health plan • Information and decision-making

9. Pilot Study to Demonstrate Effectiveness • 200 Medicaid cases (using >10 medications & 2 or more state services) under age 65 in two counties • Homogeneity on funding source • Randomly assigned to intervention and comparison groups • Consent with potential for delayed treatment

10. Timeline for Project • Acceptance of model (2003-2005) 2 years • IRB Approval (5 state agencies) Fall, 2005 • Business plan (May, 2005) Ongoing communication within university system • Created a Board of Directors and EIN number (November, 2005) • Hiring staff: (Fall, 2005) • Staff training (difference between CNS and CNL; family empowerment training for nurse and pharmacist) (December, 2005) • Some nurses and most of the pharmacists “don’t get it”

11. Predicted Outcomes Evaluation Measures • Pharmacy Outcomes:• Reduced rate of Adverse Drug Effects • Improved family/caregiver knowledge of prescribed medications • Reduced pharmacy cost • Reduced number of drugs • Medical Care Outcomes: • Less fragmentation of providers, reduced number of providers • Reduced rate and cost of emergency room, technical, and institutional care • Coordinated medical and pharmacy treatment among medical providersCase-finding: family member needs

12. Outcomes Evaluation Measures (Continued) • CDC Health Related Quality of Life • Summary index of unhealthy days • Activities Limitation Module • Healthy Days Symptoms Module • Human Capital Development:• Achievement of family plan goals • Cross Agency Coordination:• Discovery and recommendation for managing high cost families

13. CNL vs CHN • Same or different? • CHN/PHN responsible for core public health functions • CNL: generalist leader in practice • New Service Model is an opportunity to demonstrate effectiveness of generalist practice • Economic indicators/ Bottom line= cost savings • Implications for education

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