Applying the Evidence to Clinical Practice: Utilizing an Advanced Practice Nurse-Led Transitional Care Model to Improve Health Outcomes of High Risk Elders with Heart Failure Living at Home

2.50
Hdl Handle:
http://hdl.handle.net/10755/308081
Category:
Abstract
Type:
Presentation
Title:
Applying the Evidence to Clinical Practice: Utilizing an Advanced Practice Nurse-Led Transitional Care Model to Improve Health Outcomes of High Risk Elders with Heart Failure Living at Home
Author(s):
Steeg, Linda Lazzaro
Lead Author STTI Affiliation:
Non-member
Author Details:
Linda Lazzaro Steeg, DNP,RN, MS, APRN-BC, llsteeg@buffalo.edu
Abstract:

Session presented on: Tuesday, November 19, 2013

Background: In 2007, the Center for Medicare/Medicaid Services (CMS) estimated expenditures of $15 billion dollars for Medicare beneficiaries on “churning”, a term used to describe the movement of vulnerable elders from hospital to community and back again. Further, CMS estimates that 76% of these readmissions to hospitals were preventable, noting that 64% of those readmitted had received no post-discharge community follow-up. Various models of transitional care have evolved as initiatives which address the quantitative and qualitative costs of churning. The Transitional Care Model(TCM), developed by Naylor and colleagues, utilizes Masters prepared Advanced Practice Nurses (APRNs) whose expertise matches the needs of the specific vulnerable population for whom they are providing care, for example, elders with Heart Failure.

Methods: This descriptive study evaluated care delivered by APRNs to elders with Heart Failure residing at home. Retrospective chart reviews of a convenience sample (n=15) were completed. The six clinical elements defined by the ACCF/AHA 2009 Clinical Practice Guidelines(CPGs) for the Management of Heart Failure and  four Clinical Practice Categories of The Omaha Classification System were used as criteria against which to evaluate the care delivered. Additionally, readmissions and frequency of visits to the Emergency Department were evaluated at 30, 60 and 90 days.

Results: This study demonstrated that care delivered by the APRNs was consistent with 2009 ACCF/AHA CPG’s for the Management of Heart Failure.  Further, care delivered by the APRNs addressed the Clinical Practice Categories. Evidence of medication reconciliation and ongoing medication decision making was demonstrated for the 15 cases across the 12 months of the study. Additionally, care delivered by the APRNs was effective in eliminating readmissions at 30,60 and 90 days and decreasing visits to the Emergency Department at 30, 60 and 90 days, furhter supporting the APRNs' abilities to keep people well across time.

Keywords:
Elders; Advanced Practice Nurse; Heart Failure
Repository Posting Date:
19-Dec-2013
Date of Publication:
19-Dec-2013
Conference Date:
2013
Conference Name:
42nd Biennial Convention
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
Indianapolis, Indiana, USA
Description:
42nd Biennial Convention 2013 Theme: Give Back to Move Forward. Held at the JW Marriott
Note:
This is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen_GB
dc.type.categoryAbstracten_GB
dc.typePresentationen_GB
dc.titleApplying the Evidence to Clinical Practice: Utilizing an Advanced Practice Nurse-Led Transitional Care Model to Improve Health Outcomes of High Risk Elders with Heart Failure Living at Homeen_GB
dc.contributor.authorSteeg, Linda Lazzaroen_GB
dc.contributor.departmentNon-memberen_GB
dc.author.detailsLinda Lazzaro Steeg, DNP,RN, MS, APRN-BC, llsteeg@buffalo.eduen_GB
dc.identifier.urihttp://hdl.handle.net/10755/308081-
dc.description.abstract<p>Session presented on: Tuesday, November 19, 2013</p><b>Background</b>: In 2007, the Center for Medicare/Medicaid Services (CMS) estimated expenditures of $15 billion dollars for Medicare beneficiaries on “churning”, a term used to describe the movement of vulnerable elders from hospital to community and back again. Further, CMS estimates that 76% of these readmissions to hospitals were preventable, noting that 64% of those readmitted had received no post-discharge community follow-up. Various models of transitional care have evolved as initiatives which address the quantitative and qualitative costs of churning. The Transitional Care Model(TCM), developed by Naylor and colleagues, utilizes Masters prepared Advanced Practice Nurses (APRNs) whose expertise matches the needs of the specific vulnerable population for whom they are providing care, for example, elders with Heart Failure. <p><b>Methods: </b>This descriptive study evaluated care delivered by APRNs to elders with Heart Failure residing at home. Retrospective chart reviews of a convenience sample (n=15) were completed. The six clinical elements defined by the ACCF/AHA 2009 Clinical Practice Guidelines(CPGs) for the Management of Heart Failure and  four Clinical Practice Categories of The Omaha Classification System were used as criteria against which to evaluate the care delivered. Additionally, readmissions and frequency of visits to the Emergency Department were evaluated at 30, 60 and 90 days. <p><b>Results:</b> This study demonstrated that care delivered by the APRNs was consistent with 2009 ACCF/AHA CPG’s for the Management of Heart Failure.  Further, care delivered by the APRNs addressed the Clinical Practice Categories. Evidence of medication reconciliation and ongoing medication decision making was demonstrated for the 15 cases across the 12 months of the study. Additionally, care delivered by the APRNs was effective in eliminating readmissions at 30,60 and 90 days and decreasing visits to the Emergency Department at 30, 60 and 90 days, furhter supporting the APRNs' abilities to keep people well across time.en_GB
dc.subjectEldersen_GB
dc.subjectAdvanced Practice Nurseen_GB
dc.subjectHeart Failureen_GB
dc.date.available2013-12-19T17:26:39Z-
dc.date.issued2013-12-19-
dc.date.accessioned2013-12-19T17:26:39Z-
dc.conference.date2013en_GB
dc.conference.name42nd Biennial Conventionen_GB
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen_GB
dc.conference.locationIndianapolis, Indiana, USAen_GB
dc.description42nd Biennial Convention 2013 Theme: Give Back to Move Forward. Held at the JW Marriotten_GB
dc.description.noteThis is an abstract-only submission. If the author has submitted a full-text item based on this abstract, you may find it by browsing the Virginia Henderson Global Nursing e-Repository by author. If author contact information is available in this abstract, please feel free to contact him or her with your queries regarding this submission.en_GB
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