Clinical Nurse Leader: Promoting Family Health

1. Clinical Nurse Leader: Promoting Family Health Pamela N. Clarke and Carol Macnee Fay W. Whitney School of Nursing University of Wyoming

2. National Need for Clinical Leadership • Health counseling has been evolving as cost efficient service [Kaiser; Healthsource] • Nursing is natural fit [vs physicians, trained counselors or social workers] • Families need guidance negotiating the system and information (integration of care) • AACN’s CNL Movement: community approach

3. Clinical Nurse Leader in Community Health • Masters prepared CHN • Fit with model of care proposed in the state and AACN CNL • AACN competencies critical to the model • Generalist • Educator • Integration of care • Advocate • Population competencies • Acute vs community focus

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 • Lack of care coordination is critical • PHNs • Working in under-funded health departments • Inadequately prepared

5. New Service Model • Public-Private partnership • Builds on PharmAssist Program (direct service to individual re medication regimen) • Timing of Wyoming project coincided with national Clinical Nurse Leader movement • Need for data to support new model (business perspective…efficient and effective)

6. Public-Private Partnership • University of Wyoming: College of Health Sciences (nursing and pharmacy) • Human Capital Management Services (HCMS): manages all state health data (Medicaid, state health plan, uninsured) • Data indicate families need help negotiating care system • Need for family service model: MS prepared nurse and pharmacist [interprofessional team]

7. 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

8. 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

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

10. Innovation: What’s New? • Funding!! Use of business model to “sell” the value of community health nursing • Partnership with private business & state agencies • Advocacy: Family negotiates with own providers • Motivational Interviewing • Highly skilled communication techniques to accomplish goals • Potential for demonstration of cost effectiveness • Especially w/ end of life care • Care of people w/ chronic illness

11. Family-focused (services directed toward family health and welfare) Empowerment (nurse teaches family advocacy skills) Family-driven (family members contact provider/physician) Home-based case management (medical model) Individual Patient Focus (case) Advocacy on behalf of patient Service Provider-driven(case manager contacts provider/physician) CNLCase Manager

12. Pilot Study through HCMS • 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

13. 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 • Board of Directors and EIN number (November, 2005) • Hiring staff: Service separate (Fall, 2005) • Staff training (difference between CNS and CNL; family empowerment training for nurse and pharmacist) (December, 2005)

14. 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

15. 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

16. Preliminary Findings • Referrals received to date: 178 people • Enrolled: 93 participants • Age break down: • < 5yrs n=18 • 3-14 n=18 • 15-24 n=16 • 25-34 n=18 • 35-54 n=12 • 55-64 n=11 • Female n=61 Male n=32

17. Preliminary Findings: CDC Health Related Quality of Life • Forty-three percent describing health as fair to poor • Nationally 14.2% report fair to poor health (2003) • In Wyoming 12.3% report fair to poor health (2003) • Thirty-six percent describe frequent mental distress • In Wyoming 9.1% reported frequent mental distress (2003) • Averaged 8.7 days w/ poor physical health • Nationally the average is 3.4 days • Averaged 9.9 days w/ poor mental health • Nationally the average is 3.5 days • Averaged 8.4 days where poor health limited usual activities • Nationally the average is 2.0 days

18. Implications • This study of the CNL role is tackling some of the most needy clients in the state • Pro = Lots of room for improvement • Con= Very complex cases with great needs

19. END • Questions? Please email them to jstanley@aacn.nche.edu