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Defining a Gap in Practice: Executive Summary

Susie Mayo

Capella University

MSN FP6614-Struc Process in Care Coord

Dr. Clare Foshey

March 2021

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Defining a Gap in Practice: Executive Summary

This summary will analyze clinical priorities for the Medicare-approved hip and knee

replacement population to influence health outcomes utilizing care coordination processes with a

PICOT question addressing a gap in practice for care coordination. Care coordination services

and resources available for this population will be evaluated using evidence-based practice care

coordination interventions to best care for this population. A selected nursing diagnosis will

support collaborative care strategy with a discussion of intervention planning and expected

outcomes for the care coordination process using the scope and standards of practice for care

coordination.

Clinical Priorities for Lower Joint Replacement Population to Influence Outcomes

Many hospitals require their Medicare-approved lower joint replacement surgery patients

to attend pre-surgical education with the care coordination team. This pre-surgery education's

primary focus is to assess and address any social determinants of health(SDOH) patients may be

experiencing before surgery in order to improve care quality, avoid discharge delays, control

costs after hospital discharge, and prevent readmissions(Centers for Medicare & Medicaid

Services, n.d.). Hospitals are penalized for less than 30-day readmissions, skilled nursing

facility(SNF) spending, and how hospitals chose to reduce these costs is their decision (Zhu et

al., 2018). Hospitals are moving more toward home-based care and are hiring dedicated care

coordination staff such as community health workers(CHW) to continue to follow up patient care

once skilled home health services are discontinued to ensure patients continue with their home

care plan(Zhu et al., 2018). The guidance of CHWs helps patients keep follow-up appointments

and assist with any needed resources, including monitoring and reporting of health outcomes to

the primary physician or surgeon. CHWs are a part of a collaborative team such as nurse case

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managers, social workers(SW), and dieticians who work behind the scenes from medical

practices to assist patients with high risk or complex care needs to decrease high emergency

department (ED) utilization and readmissions. Zhu et al., 2018 report there is much literature

reporting on the benefits of home-based care utilizing CHWs, but there is a gap in knowing

whether home discharges post-surgery without assistance from CHWs could increase hospital

readmissions or harm patients with more complex needs(p.1286).

PICOT Question

In adult patients with total lower joint replacement surgery (Population), how effective is

the use of CHWs in home-based care after surgery (Intervention) compared to home discharges

without the use of CHWs(Comparison) in improving quality of care and recovery (Outcome)

during the postoperative and recovery time (Time)?

Selected Gap Explanation

Once discharged from the hospital to home and when skilled services are completed, the

real struggle is getting the patient to participate in their care for the long haul and maintain

compliance with the healthcare plan and follow-up appointments(Kangovi et al. 2020). The

assumption can not be made that all CHW's efforts will prevent unnecessary (ED) visits. There

will always be behaviors that can not be changed, patients who refuse to participate in care

coordination and remain non-compliant, and those who continually make poor healthcare

choices(Zhu et al.,2018). Zhu et al., 2018 also report that they did not interview care coordinators

or CHWs whose perspectives may differ from those of healthcare providers and surgeons

regarding their views concerning the impact of utilizing CHWs or not in the homes for

postsurgical patients(p.1284).

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Available Care Coordination Services and Resources

Care coordination with the patient and family starts before surgery. The surgeon's office

collaborates with hospital case managers, surgical unit nurses, home health liaisons, physical

therapists, and pharmacists to provide weekly joint class education to scheduled joint

replacement patients. The weekly education classes are arranged by the office surgery scheduler

for the patients. Patients attend the class in the hospital, so they know exactly where to come on

the day of surgery. A sit-down discussion is held, and each hospital discipline talks with the

patients and any family who attend to discuss surgery, home-going expectations, medications,

social determinants of health(SDOH), caregiver role, and durable medical equipment(DME). A

question and answer session for the patients and families is offered at the end of the class. The

goal is to meet face to face with patients and families, assess needs, prepare patients for home-

going in an attempt to avoid unnecessary discharge delays and skilled nursing facility(SNF)

referrals(Mendel et al., 2018). This pre-surgery education also helps patients plan pre-surgery

interventions and educated them on expected outcomes after surgery. Patients and families

receive education regarding transitions to a CHW once skilled services are complete. In this

collaborative relationship with patients and families, a sense of trust develops with their provider,

and patients meet a team member who will be caring for them in the hospital, which gives a

sense of empowerment to patients and families(Zhu et al.,2018).

Evidence-based Care Coordination Intervention

The care coordination guidance provided to the Medicare-approved hip and knee

replacement population is based on The Registered Nurse- Care Coordination Transition

Management Model (RN CCTM). The American Academy of Ambulatory Care Nursing (2016)

states this model focuses on individualized patient-centered assessment and care planning and

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evolved to standardize all registered nurses' work using evidence from nursing and

interprofessional literature on care coordination and transition management(p.8). The RN CCTM

model focuses on care coordination and collaboration with the entire multidisciplinary team and

offers a person-centered approach to patient care to empower and encourage patients to

collaborate with their health care providers. A critical element of care coordination is preparing

for the transition management of care, and this is where the use of CHWs plays a role. Transition

management provides ongoing support to patients and families as they navigate their longitudinal

healthcare journey(The American Academy of Ambulatory Care Nursing, 2016). Care

coordination is about assessing individual care needs, tailoring care to that patient, identifying

patient risks, and based on those risks or needs continue care services best suited for the

transition management care.

Nursing Diagnosis

Readiness for Enhanced Individual Coping as evidenced by verbalization of desire to

information from community health coach that will enhance optimal health outcomes and

improve healing(Phelps et al., 2017).

Issue Assessment

The patient will display a readiness for enhanced individual coping by collaborating with

the care coordination team by expressing a willingness to accept further assistance from the

CHW to achieve optimal health outcomes and improved healing by maintaining follow-up

appointments and accepting community resources and guidance from the CHW.

Planning Interventions and Expected Outcomes

First, a multidisciplinary collaboration needs to begin at the start of care, not just before

the transition, including the patient and family(American Academy of Ambulatory Care Nursing,

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2016). Next, care coordination needs to identify patients at risk for unnecessary readmission or

ED utilization by assessing health literacy, SDOH, confidence in self-care, the complexity of any

comorbidities, and their discharge condition(American Academy of Ambulatory Care Nursing,

2016). Lastly, transitional planning is more than the patient's discharge instructions; it involves

coordination with all of the appropriate care providers necessary to ensure that the patient is

effectively transitioned home with understandable discharge instructions, home health services,

and determining the need for a CHW once skilled services are complete(American Academy of

Ambulatory Care Nursing, 2016).

To achieve outcomes for patients and families, the goals need to be achievable based on

their preferences and values, and it is essential to include them in decision making(American

Academy of Ambulatory Care Nursing, 2016).

Expected outcomes will be evidenced by patients and families verbalizing understanding

of referred community resources and maintaining follow-up appointments arranged by

CHW(American Academy of Ambulatory Care Nursing, 2016).

The family and patient will accurately describe the disease process, feelings about self-

management of their healthcare, and healthcare follow-up(American Academy of Ambulatory

Care Nursing, 2016).

Outcomes will guide care across the healthcare continuum using a holistic, person-

centered, evidence-based approach in attaining those patient goals(American Academy of

Ambulatory Care Nursing, 2016).

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References

American Academy of Ambulatory Care Nursing (2016). Scope and Standards of Practice

for Registered Nurses in Care Coordination and Transition Management. 1-40.

https://ebookcentral-proquest-com.library.capella.edu/lib/capella/detail.action?

docID=4768806#

Centers for Medicare & Medicaid Services. (n.d.). BPCI Model 2: Retrospective acute & post-

acute care episode | CMS innovation center. CMS Innovation Center CMS Innovation

Center. https://innovation.cms.gov/innovation-models/bpci-model-2

Kangovi, S., Mitra, N., Grande, D., Long, J. A., & Asch, D. A. (2020). Evidence-based

community health worker program, addresses unmet social needs and generates positive

return on investment. Health Affairs, 39(2), 207-213,213A-213C.

doi:http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2019.00981

Mendel, P., Chen, E. K., Green, H. D., Armstrong, C., Timbie, J. W., Kress, A. M., Friedberg, M.

W., & Kahn, K. L. (2018). Pathways to Medical Home Recognition: A Qualitative

Comparative Analysis of the PCMH Transformation Process. Health services

research, 53(4), 2523–2546. https://doi.org/10.1111/1475-6773.12803

Naylor, J. M., Hart, A., Harris, I. A., & Lewin, A. M. (2019). Variation in rehabilitation setting

after uncomplicated total knee or hip arthroplasty: A call for evidence-based

guidelines. BMC Musculoskeletal

Disorders, 20 doi:http://dx.doi.org.library.capella.edu/10.1186/s12891-019-2570-8

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Phelps, L. L., Ralph, S. S., & Taylor, C. M. (2017). Sparks and Taylor's Nursing Diagnosis

Reference Manual (Tenth rev. ed.). Wolters Kluwer Health.

Zhu, J. M., Patel, V., Shea, J. A., Neuman, M. D., & Werner, R. M. (2018). Hospitals Using

Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care

Integration. Health Affairs, 37(8), 1282-1289,1289A-1289B.

http://dx.doi.org.library.capella.edu/10.1377/hlthaff.2018.0257

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