The Role of the CNS in Transitioning the Frail Elderly

1. The Role of the CNS in Transitioning the Frail Elderly Ellen McPartland, MSN, CNS, CRNP Pennsylvania Hospital University of Pennsylvania Health System Octobers 26, 2012

2. Presentation Objectives • Provide a common health care scenario of a high risk frail elderly patient transitioning from hospital to home • Describe the key concepts supporting the Transitional Care Model • Discuss the core competencies of the CNS • Summarize key findings from testing of the TCM led by an APN/CNS • Describe the impact of the body of evidence from testing the TCM from clinical practice and future healthcare initiatives

3. A common scenario from hospital discharge to home • Mr. Smith, a 76 year old male admitted to an acute care hospital for exacerbation of CHF. • PMH includes HTN, Hyperlipidemia, A-fib, CAD, COPD, DM, hypothyroidism, and prior ischemic stroke • Nine daily medications • Patient follows up with an internist and 2 specialists for his multiple health conditions • Second hospitalization in 3 months

4. Scheduled for Discharge to Home after 2-Day Length of Stay • Discharge instructions include 3 medication changes and a sodium restricted diet. • His 76 year old wife has a similar profile of chronic health problems and is too frail to visit him in the hospital, so he takes a cab home. • Both have undiagnosed cognitive impairment and have lost some executive function. • They have no children, but receive help from neighbors.

5. How will they manage the transition back to their usual state of health given the support provided by “usual care?”

6. If they are fortunate… • Their internist will receive timely communication from the hospital re: Mr. Smith’s illness and treatment received. • He will be seen in the office soon after discharge to detect and manage residual health problems. • The local pharmacist will know Mr. Smith and will reconcile his previous and new medications and may even consider the couple’s cognitive function in the dispensing plan. • The discharge planner may have consulted a home care nurse who will visit within a few days. The neighbors may check on them.

7. On the Other Hand… Maybe the Smiths will fall through the enormous cracks in our current health care system and none of these supports will take place... …Or maybe they will receive care from a APN such as the Clinical Nurse Specialist.

8. Patient Factors Contributing to Poor Outcomes Multiple chronic conditions Functional deficits Cognitive Impairment Lack of support Poor general health behaviors Language and cultural barriers Problems with health literacy

9. Multiple providers Inconsistent medical management Poor communication Poor Health literacy Limited access to services (reimbursement) Narrow perceived accountability Lack of systems to bridge transitions Poor Outcomes: System Factors

10. At Risk Population Such as the Frail Elderly • Frailty is a multi-dimensional cluster of common factors that contribute to diminish independence in activities of daily living. • It is most prevalent among the old, especially those who are 75 years of age or more. • The clusters can include physical dysfunction, cognitive/psychological impairments, and or social-economic and nutrition problems. • (Levers, Estabrooks, & Kerr, 2006).

11. The Case for Transitional Care • Huge gaps in care • Serious unmet needs • Poor care experiences, esp. for cognitively impaired older adults + family caregivers • High rates of medical errors • High rates of preventable readmissions • Tremendous human & cost burden

12. Transitional Care • A range of time limited services that complement primary care and are designed to ensure health care continuity and avoid preventable poor outcomes among at risk populations as they move from one level of care to another, among multiple providers and across settings. • Designed to bridge gaps that occur as a result of having multiple players involved in care or to bridge the gaps that occur when a patient moves from one site of care to another.

13. The Importance of the APN-led Transition from Hospital to Home • A time when miscommunication and misinformation can occur. • A time when much patient/family educating, coaching and guidance is needed. • A time when having the knowledge and skills to navigate a complicated health care system is needed. • A time when collaboration and coordination of care is needed to prevent an avoidable rehospitalization.

14. Three Spheres of Influences Core Competencies of the CNS A clinical expert Educating, coaching, and guidance adaptable to patient/family or groups Clinical professional and leadership skills Skilled in ethical decision making Collaboration Consultation Research

15. Evolution of the Transitional Care Model • Developed in 1980 as a response to shortened hospital lengths of stay. • Pressure to provide effective health care services at lowest cost. • Initially tested with early discharge of low birth weight infants. • Recently the model has been applied to improve outcomes and reduce cost of care for hospitalized elders.

16. Since 1989, Dr. Naylor has led an interdisciplinary program of research designed to improve outcomes and reduce costs of care for vulnerable community-based elders. Her work is focused on discharge planning and home follow-up of high-risk elders by advanced practice nurses. Through her research, Dr. Naylor has added to what is known about advanced practice nursing and transitional care. Mary D. Naylor, Ph.D., R.N., FAAN Marian S. Ware Professor in Gerontology Director, New Courtland Center for Transitions and Health

17. Transitional Care Model

18. Key Components • Focus on Patient and Caregiver Understanding • Helping Patients Manage Health Issues and Prevent Decline • Medication Reconciliation and Management • Transitional Care, Not Ongoing Case Management

19. Transitional Care Model - APNC Care is delivered and coordinated …by same advanced practice nurse …across settings …7 days per week …using evidence-based protocol …with focus on long term outcomes

20. National Average Readmission Rate at 52w: 56.1% 1Naylor et al. Comprehensive discharge planning for the hospitalized elderly. Ann Intern Med. 1994;120:999-1006. 2 Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized clinical trial. JAMA. 1999;281:613-620. 3 Naylor et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.

21. + Total costs were calculated using average Medicare reimbursements for hospital readmissions, ED visits, physician visits, and care provided by visiting nurses and other healthcare personnel. Costs for TCM care is included in the intervention group total. ** Naylor et al. Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized clinical trial. JAMA. 1999;281:613-620. *** Naylor et al. Transitional care of older adults hospitalized with heart failure: a randomized, controlled trial. J Am Geriatr Soc. 2004;52:675-684.

22. Enhancing Transitional Care for Cognitively Impaired Older Adults and Their Family Caregivers (ECC) Study Sites

23. Study Aim Test care innovations among hospitalized cognitively impaired older adults, designed to: • Improve the care experience • Enhance function & quality of life • Minimize caregiver burden • Prevent avoidable rehospitalizations • Decrease health care costs

24. Patient Demographics • Age: 80.7 ± 7.7 (65-102) years • Female: 67.5% • African American: 59.4% • Education: 11.7±3.4 (2-25) years

25. Patients’ Clinical Characteristics Percentages may not add to 100% due to rounding. Median number of co-morbidities, 5 (range: 0-13) Median number of medications, 8 (range: 0-27)

26. Rates and Types of Patients’ Cognitive Deficits • 54.2% deficits in orientation/recall • 16.2% diagnosis of dementia • 24.7% delirium (+ Confusion Assessment Method) • MMSE: 21.9 ± 5.4 (2-30) [n=268]

27. Caregiver Demographics • Age: 58.6±13.9 (18-93) years • Female: 74.2% • African American: 58.3% • Education: 13.7±2.7 (5-26) years • Relationship to Patient:

28. Caregiver Burden Although overall burden was low, higher CG burden was highly associated with: • ↓MMSE scores • Presence of delirium • Patient depressive symptoms • CG depressive symptoms • Patient having diagnosis of dementia .

29. Clinical Information System & Data Collection • Developed a clinical information system with a relational database to house our tools • Chose the Omaha System for standardized documentation as it helped to determine “what did the nurses do?” • Problem classification Scheme ( client assessment) • Intervention Scheme ( care plans and services) • Problem Rating Scale for outcomes( Client change/evaluation)

30. Results • 271 Patients-Caregiver dyads • Over a period of 1-3 months • Average 13.6 visits & 13.9 phone calls • Identified on average 4.5 problems per patient (range 1-11) • Conducted on average 158 interventions per patient

31. Readmission Rates by Group* * Using Kaplan-Meier estimates, weighted by propensity scores + Jenks et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. N Engl J Med 2009; 360:1418-1428

32. Results Patient Problems • The complexity of care was evident with 71% of the 42 Omaha System problems present in the sample. • Most common problems were:

33. Signs and Symptoms • Patients experienced 188 discrete signs and symptoms • Average 11.5 (range 1-41) • Most common symptoms managed by APNs were:

34. Interventions A total of 42,949 interventions were completed.

35. Using Qualitative Methods to Describe APN Care* • Theme #1: Having the Necessary Information and Knowledge • Theme #2: Care Coordination • Theme #3: Caregiver Experience Bradway, C., et al. (2011)

36. Theme #1: Having the Necessary Information and Knowledge Barriers Facilitators Rapid identification of gaps in knowledge and educational needs Innovative strategies to get information to dyads Trusting relationship, support via APN-directed protocol, shared understanding of goals • Low health literacy • Lack of knowledge of chronic illness • Lack of acknowledgement of severity or implications of illness • Compounded by CI

37. Theme #2: Care Coordination Barriers Facilitators APN advanced skills and collaboration with other heath care providers Worked tirelessly to achieve goals and coordinate care Went “above and beyond” typical care by doing everything necessary to identify and ensure success • Difficulty scheduling appointments • Missed appointments • Refusal of services

38. Theme #3: Caregiver Experience Barriers Facilitators APNs reach out by multiple means and over and over again as needed Staying in close contact Helped dyads understand and accept chronic conditions • Overwhelmed CGs • Poor coordination among multiple CGs

39. Study Conclusions/Discussion • “What did the nurses do?” • The ability to retrieve the APNs documentation showed the: • Complexity of patients • Most common problems experienced • Large range of symptoms • Vast amount of education we provide • Critical challenges and facilitators to providing care can be identified and used to plan care and policy

40. Translating to Clinical Practice QI Priorities/Opportunities* • Best practices for gathering, storing, and communicating patient information • Training to recognize “at risk” patients • Technology for monitoring high-risk patients • Addressing advance directives • Coordinating follow-up care * Golden, et al, 2010

41. The TCM: Summary/Conclusions • A well-established model of care • Evidence of effectiveness • Significant APN role with focus on inter-professional team • Translation of the TCM into practice • Future research: • Examination of the TCM with additional populations and in other settings • Nursing home to hospital transitions • Specialty populations

42. Resources and References • Bradway, C., et al. (2011) A qualitative analysis of an advanced practice nurse-directed transitional care model intervention. The Gerontologist. Doi: 10. 1093/geront/gnr078 • Jenks et al. Rehospitalizations among Patients in the Medicare Fee-for-Service Program. New England Journal of Medicine 2009; 360:1418-1428 • Levers, M.J.,et al.(2006). Factors Contributing to Frailty: literature review. J Adv Nurs, 56 (3): 282-91 • Naylor, M., et al. (1999). Comprehensive discharge planning and home follow-up of hospitalized elders: A randomized controlled trial. JAMA, 281, 613-620.

43. Resources and References • Naylor, M.D., et al. (2009). Translating research into practice: Transitional care for older adults. Journal of Evaluation in Clinical Practice, 15, 164-1170. • Naylor, M. D., et al. (2007). Care coordination for cognitively impaired older adults and their caregivers. Home Health Care Services Quarterly, 26(4), 57-78. • Naylor, M.D., et al. (2010). Enhancing care coordination for cognitively impaired older adults and their family caregivers. Gerontologist, 50(S1), 50. doi: 10.1093/geront/gnq115 • www.transitionalcare.info • www.caretransitions.org