Enhanced Patient and Caregiver Engagement Drive Utilization and Quality Outcomes in an Advanced Practice Nurse-Led Care Transitions Interventin With Super Utilizers

2.50
Hdl Handle:
http://hdl.handle.net/10755/338427
Category:
Full-text
Type:
Presentation
Title:
Enhanced Patient and Caregiver Engagement Drive Utilization and Quality Outcomes in an Advanced Practice Nurse-Led Care Transitions Interventin With Super Utilizers
Author(s):
Williams, Megan McNamara
Lead Author STTI Affiliation:
Non-Member
Author Details:
Megan McNamara Williams, BA, BSN, MSN, DNP, mwilliams@beebehealthcare.org
Abstract:
Session presented on Friday, September 26, 2014: Background: Care transitions across the health care continuum have been the focus of numerous efforts of health care systems throughout the United States in the last few decades. Poorly managed transitions can result in poor health outcomes and have tremendous financial implications for both patients and healthcare systems. In an effort to address poor transitions in care and minimize waste in the health care system, several approaches to the provision of transitional care have been tested and are still currently underway. Congruent with the triple aim, improving the experience of care, improving the health of populations, and reducing per capita costs of health care, health care facilities, clinicians and patients have been working together to establish effective programming and interventions to improve transitions in care, reduce health care ending and optimize the quality and safety of care provided to patients across the care continuum. Current shortcomings in the U.S. health care system have a profound impact on the chronically ill, who experience repeated changes in health status accompanied by numerous transitions between providers and care settings. The common thread among all of the successful transitional care models has been the presence of nurses, as clinical leaders or care managers. Advanced Practice Nurses possess the clinical and interpersonal skills, in-depth knowledge of systems and how to work within them to affect positive patient outcomes and keep patients well during vulnerable transitions in care. Objectives: To explore the impact of a 90 day Advanced Practice Nurse-led transitional care program, specifically the incorporation of health coaching and the resulting impact on readmissions, cost of care, patient transition skills and quality of life. Results: The intervention population (n = 142, M= 0.59 re-admissions, SD= 0.84) demonstrated a 30% overall reduction in re-admissions compared to the pre-program re-admission population (M= 0.85 re-admissions, SD= 0.47, t (1,136) = -3.82, p= < .001. The intervention resulted in over a three-fold increase in average transition skills scores, t (1, 136) = 19.20, p < .00001 and 2.5 fold improvement in quality of life among intervention participants t (1, 136) = -11.99, p< .00001). The resulting impact on cost of care was a total reduction in cost of $1,534,330, with an average of $12,276 reduction per participant, t (1, 141) = 3.79, p < .001). Conclusion: As the health care industry moves forward in pursuit of the best way to provide care for patients across the entire continuum of care, the focus should be on optimizing both utilization and quality of life for the most vulnerable populations through the provision of Advanced Practice Nurse- led transitional care emphasizing health coaching and patient and caregiver engagement. Incorporation of models of care, based in the nursing paradigm, augmented by interdisciplinary collaboration and emphasizing patient engagement through health coaching should be a focus for future research and serve as the basis for transitional care programs nationwide.
Keywords:
Transitional Care; Advanced Practice Nurse
Repository Posting Date:
15-Jan-2015
Date of Publication:
15-Jan-2015
Other Identifiers:
LEAD14PST132
Conference Date:
2014
Conference Name:
Leadership Summit 2014
Conference Host:
Sigma Theta Tau International, the Honor Society of Nursing
Conference Location:
Indianapolis, Indiana, USA
Description:
Leadership Summit 2014 Theme: Personal. Professional. Global. Held at the Indianapolis Marriott Downtown, Indianapolis.
Note:
Items submitted to a conference/event were evaluated/peer-reviewed at the time of abstract submission to the event. No other peer-review was provided prior to submission to the Henderson Repository.

Full metadata record

DC FieldValue Language
dc.language.isoen_USen
dc.type.categoryFull-texten
dc.typePresentationen
dc.titleEnhanced Patient and Caregiver Engagement Drive Utilization and Quality Outcomes in an Advanced Practice Nurse-Led Care Transitions Interventin With Super Utilizersen_US
dc.contributor.authorWilliams, Megan McNamaraen
dc.contributor.departmentNon-Memberen
dc.author.detailsMegan McNamara Williams, BA, BSN, MSN, DNP, mwilliams@beebehealthcare.orgen
dc.identifier.urihttp://hdl.handle.net/10755/338427-
dc.description.abstractSession presented on Friday, September 26, 2014: Background: Care transitions across the health care continuum have been the focus of numerous efforts of health care systems throughout the United States in the last few decades. Poorly managed transitions can result in poor health outcomes and have tremendous financial implications for both patients and healthcare systems. In an effort to address poor transitions in care and minimize waste in the health care system, several approaches to the provision of transitional care have been tested and are still currently underway. Congruent with the triple aim, improving the experience of care, improving the health of populations, and reducing per capita costs of health care, health care facilities, clinicians and patients have been working together to establish effective programming and interventions to improve transitions in care, reduce health care ending and optimize the quality and safety of care provided to patients across the care continuum. Current shortcomings in the U.S. health care system have a profound impact on the chronically ill, who experience repeated changes in health status accompanied by numerous transitions between providers and care settings. The common thread among all of the successful transitional care models has been the presence of nurses, as clinical leaders or care managers. Advanced Practice Nurses possess the clinical and interpersonal skills, in-depth knowledge of systems and how to work within them to affect positive patient outcomes and keep patients well during vulnerable transitions in care. Objectives: To explore the impact of a 90 day Advanced Practice Nurse-led transitional care program, specifically the incorporation of health coaching and the resulting impact on readmissions, cost of care, patient transition skills and quality of life. Results: The intervention population (n = 142, M= 0.59 re-admissions, SD= 0.84) demonstrated a 30% overall reduction in re-admissions compared to the pre-program re-admission population (M= 0.85 re-admissions, SD= 0.47, t (1,136) = -3.82, p= < .001. The intervention resulted in over a three-fold increase in average transition skills scores, t (1, 136) = 19.20, p < .00001 and 2.5 fold improvement in quality of life among intervention participants t (1, 136) = -11.99, p< .00001). The resulting impact on cost of care was a total reduction in cost of $1,534,330, with an average of $12,276 reduction per participant, t (1, 141) = 3.79, p < .001). Conclusion: As the health care industry moves forward in pursuit of the best way to provide care for patients across the entire continuum of care, the focus should be on optimizing both utilization and quality of life for the most vulnerable populations through the provision of Advanced Practice Nurse- led transitional care emphasizing health coaching and patient and caregiver engagement. Incorporation of models of care, based in the nursing paradigm, augmented by interdisciplinary collaboration and emphasizing patient engagement through health coaching should be a focus for future research and serve as the basis for transitional care programs nationwide.en
dc.subjectTransitional Careen
dc.subjectAdvanced Practice Nurseen
dc.date.available2015-01-15T13:37:30Z-
dc.date.issued2015-01-15-
dc.date.accessioned2015-01-15T13:37:30Z-
dc.conference.date2014en
dc.conference.nameLeadership Summit 2014en
dc.conference.hostSigma Theta Tau International, the Honor Society of Nursingen
dc.conference.locationIndianapolis, Indiana, USAen
dc.descriptionLeadership Summit 2014 Theme: Personal. Professional. Global. Held at the Indianapolis Marriott Downtown, Indianapolis.en
dc.description.noteItems submitted to a conference/event were evaluated/peer-reviewed at the time of abstract submission to the event. No other peer-review was provided prior to submission to the Henderson Repository.-
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