Provide one example, with supporting evidence, of nurses partnering with patients and families to develop an individualized plan of care based on the unique needs of the patient. AND Provide one example, with supporting evidence, of nurses partnering with patients and families to improve systems of care at the unit, service line, or organizational level.
Example 1
Provide one example, with supporting evidence, of nurses partnering with patients and families to develop an individualized plan of care based on the unique needs of the patient.
In 2012 in an effort to provide better communication and information sharing with patients communication boards in the patients rooms were updated.
These boards not only indicate members of the care team, but also discharge plans and goals for the day. The team embraced these changes and the patients found this additional information to be valuable for their hospitalization and subsequent discharge.
Over the next year, one area of opportunity was ensuring that the goals were being updated appropriately based on the patients diagnosis. The Charge Nurse along with a clinical nurse recognized that some members of staff were struggling to put plans together each day that were attainable and appropriate for the patient population. They identified the top 8 admissions that come to 3 West and outlined evidence based goals to align with the diagnosis. The clinical nurses review and update the goals with the patients on their first morning rounds. Since implementing this on 3 West the other Medical/Surgical units have adopted the same process and have come up with common plans based on their top diagnosis.
Exhibit SE4.1 Common Diagnosis and suggested care plans
Provide one example, with supporting evidence, of nurses partnering with patients and families to improve systems of care at the unit, service line, or organizational level. Example Two
Background/Problem Lack of medication adherence has been a growing concern to Cardiac Rehab clinicians at Thompson Health because of mounting evidence that it is prevalent and associated with adverse outcomes and higher costs of care. In an effort to improve patient outcomes, there has been a global effort to increase patient awareness of adverse events due to medication non-adherence. Non-adherence causes approximately 30% to 50% of treatment failures and 125,000 deaths annually. The goals of a cardiac rehabilitation program are to develop and maintain healthy lifestyles in patients with known cardiac disease to improve quality of life, reduce the risk of further cardiac events and mortality and morbidity associated with cardiac disease. The program ranges from 24-36 visits, and patients come 2-3 days per week over a period of 12 weeks. Goal Statement(s) Overall the goal of the medication compliance program was to improve participants' understanding of their medications to assist with compliance with medications to lower cholesterol and LDL blood levels. Goal 1: increase medication compliance in the Cardiac Rehabilitation program to reduce total cholesterol and LDL levels within 3 months Goal 2: Sustain the improvement for a further 3 months Description of the Intervention The cardiac rehabilitation team, including nurses, pharmacists, dieticians, diabetic educators, providers and social workers came together to devise a program to improve medication compliance in a pilot group of participants. The plan involved a number of steps:
Participants Dr. Bryan Henry, Cardiac Rehabilitation Program Director, Finger Lakes Cardiology Mary Allhusen, RN-BC, Staff Nurse, Cardiac Rehabilitation Kathy Roeland, RN, Staff Nurse, Cardiac Rehabilitation Heather Williams, RN, Staff Nurse, Cardiac Rehabilitation Darcy Prunoske, Clinical Dietician, Patient Care Services Marco Mennucci, Pharmacist, Pharmacy, Patient Care Service Jane Hallstead, MSN, RN, CDE, Diabetic Educator and Patient Education Coordinator, Patient Care Services Mary Savastano, LMSW, Director of Case Management/Social Work, Patient Care Services Outcomes This graph demonstrates that in all participants the Total Cholesterol levels were reduced from the baseline (October 2013) by the end of the 12 week Cardiac Rehabilitation program. These results were sustained in the first four patients 3 months after the program was completed. All participants had a normal cholesterol level by the end of the 12 week program and the four that reported at the 3 months post program had sustained their improvements. This graph demonstrates reduction in LDL to within normal range for all participants. There were six patients in the initial cohort. The first four patients demonstrated improvement in both Cholesterol and LDL blood levels from their baseline that was sustained at the 3 month follow up time point. Participant five left the area and participant six did not return for the final follow up. Both these participants had shown improvement at the 12 week post intervention time point but were subsequently lost to follow up. The program met its aims and is now part of the standard care for Cardiac Rehabilitation participants. Exhibit EP4.2 - Wallet Card
Exhibit EP4.3 - Welcome Back Card