Quality Improvement and Customized Care 1

QUALITY IMPROVEMENT AND CUSTOMIZED CARE 1

Individual Paper on Key Issue: Quality Improvement and Customized Care

Corinne C. Bradley

Ferris State University

Abstract

There are many changes in healthcare that are occurring at a rapid pace. A great deal of these changes requires nursing knowledge and participation in process improvement and quality control. Nurse leaders are becoming key to ensuring that quality care is provided and that patient needs are met. There are two current healthcare initiatives that support quality care through customization, including Advanced Illness Management (AIM) and Patient-Centered Medical Homes (PCMH).

Individual Paper on Key Issue: Quality Improvement and Customized Care

Quality care provision utilizing customized care plans and care coordination are pressing topics in light of current health care changes in the United States (Marshall, 2011). A major quality improvement initiative is in Advanced Illness Management (AIM) and the establishment of Patient-Centered Medical Homes (PCMH). Advanced Illness is defined as a person who has multiple conditions where standardized treatment is no longer effective (American Hospital Association (AHA), 2012). Not only is the quality of the care jeopardized for this population but the cost of care is increasing drastically. There is also the concern of multiple physicians treating the patient, polypharmacy, lack of home care support, and multiple hospitalizations. Literature supports the effectiveness of care coordination, PCMH, and enhanced self-management in increasing the quality of care and quality of life for the advanced illness patient. The purpose of this paper is to discuss AIM’s ability to increase the quality of care provided to patients, improve health disparities, how nursing supports this effort, and the true need for change to improve patient outcomes.

Literature Support

Care Coordination

Coordination of care among providers is essential to the outcomes of advanced illness patients. Dorman-Marek et al. (2013) conducted a study on the effects of nursing care coordination for advanced illness patients in regards to medication management. It was found that with the coordination of care medications were taken correctly and patient outcomes improved. The outcomes that improved did not only include medication safety, but also a decrease in depression and an increased quality of life (Dorman-Marek, 2013).

An important aspect of AIM is care coordination among the multiple providers the advanced illness patient encounters including physicians, nurses, therapists, and pharmacists (AHA, 2012). If appropriate coordination and open communication is utilized, then the patient outcomes improve drastically. An established PCMH provides the necessary coordination to ensure that patient outcomes improve. The National Committee for Quality Assurance (2013) has researched and reported on the clear benefits to an established PCMH. A medical home involves a primary care practice that develops long-term relationships with patients, coordinates care through clinical teams, coordinates care with medical specialists and community services, provides services through technology and longer hours, and promotes patient centered decision making (AHA, 2012). A great deal of this care coordination is provided through Nurse Case Managers and Advanced Practice Registered Nurses (APRN).

Advanced Practice Nursing

With the aging population growing rapidly there is a huge need for practioners to care for them. APRN’s are qualified to care for this population as well as a necessary resource (Moore & McQuestion, 2012). AIM calls for not only APRN’s but also nursing leaders to support the need of the aging population (AHA, 2012). Due to the lack of primary care physicians and the new health incentives it in even more critical to have APRNs to assist in the care of the population as a whole.

There is a concern that with the current health care initiatives, nursing staff will be called to play a more advanced role in healthcare. This is important to improve quality of care and healthcare outcomes, however the nursing staff must be appropriately trained and educated to take on these new roles. The nurse leader must ensure that staff remain practicing with in their scope of practice and support advancement through further education and certification. In order to lead by example, nurse leaders must also seek out continual education, ensuring quality patient care. Nursing as a profession must advocate for financial and institutional support for those seeking out advanced degrees.

Decision Making

With the recent healthcare changes and advances in healthcare such as AIM, patients are called to make many decisions that they may not understand or be prepared for. A focus of AIM and PCMH is to involve patients and families in decision making and care planning (Potera, 2012). Patients and their families may make decisions that the healthcare system may not understand or accept, however it is critical that these decisions are respected (Vladeck & Westphal, 2012). With quality improvement being on the forefront of healthcare initiatives, it is imperative that patients understand that they partner in their healthcare planning and decision making.

Nurse leaders need to support this collaboration toward customized care by educating staff and providers on the focus of patient-centered care and decision making. This has the potential to be met with resistance, however through transparency and open communication the nurse leader can demonstrate the importance of patient-centered care and quality improvement. As partners in the advancements in health care Nurse leaders must partner with care teams to ensure that quality measures are being established and met.

Health Disparities

Health disparities have been a key issue in health care and quality care measures need to be considered to decrease the disparities present. The PCMH has been found to decrease disparities especially among low-income populations (Berenson, Doty, Abrams, & Shih, 2012). PCMHs provide equal services to all patients regardless of the disparities that may be present. This equality in service is related to the increased reimbursement rates for PCMHs.

The Nurse leader must assist in the education of staff, provider, and the community regarding the importance of equality in healthcare. It is very common for the multiple disciplines to cast judgment and stereotypes on low income patient populations. This not only is a disservice to the patient population, but also healthcare. The nursing profession prides itself on a caring principle and this needs to be reinforced to staff to ensure equality in care is provided.

Cost Savings

AIM and PCMH allow for a collaboration and coordination of care that has been found to decrease healthcare costs. Reid et al. (2010) found that not only were costs reduces, but provider burnout decreased and patient satisfaction increased. “Observational evidence shows that when health systems emphasize primary care, patients achieve better health outcomes at a lower cost” (Reid et al., 2013, p. 842). Abernethy et al. (2013) also found the cost savings associated with coordination of care due to decreased hospitalizations of palliative care patients involved in AIM.

Takach (2011) demonstrated that due to the evidence of cost savings, many states are not only standing by but supporting PCMHs. This support comes in many forms including “learning collaboratives, disease registries, electronic health record systems, care coordinators, practice coaches, and data feedback” (Takach, 2011). By providing the necessary resources to primary care practices cost savings are drastic and patient outcomes vastly improved.

Advocating for Change

AIM and PCMH are imperative to health care today, especially in light of recent health care changes and the aging population. AIM and PCMH are pressing initiatives in healthcare that have been proven to improve patient outcomes, increase quality of care, provide patient satisfaction, and lower costs. The nursing profession is becoming a critical piece of health care initiatives and Nurse leaders play an integral role in assisting in the necessary changes. The Nurse leader must advocate for change through quality improvement measures and by utilizing change theories.

Quality Improvement

Quality improvement is a focus of healthcare overall, however the nursing profession is the direct line of care and therefore quality improvement is even more pertinent to nursing initiatives. Nurse leaders need to constantly evaluate current practices in comparison to national standards as well as process improvements. Marshall (2011) discusses eight principles of quality improvement that all Nurse Leaders should understand including, developing a vision, a focus on the process necessary for the change to occur, analysis of impacted individuals and any present barriers, coordinating partnerships among key individuals, adapting a quality committed culture, making sure that quality starts in executive and leadership roles, communicate change adequately, and ensure accountability is present for the necessary change to improve quality. The focus must always remain on team collaboration, patient-centered care, and continual improvement measures (Marshall, 2011). With the listed principles and continual improvement measures, the Nurse leader should be able to adopt the necessary change to improve the quality of care provided to patients.

Change Theory

In order to effectively initiate change, research and knowledge must be obtained and then delivered through a system or a change theory. Roussel (2013) identifies multiple change theories and theorists. Kurt Lewin is well known for his change theory and many models have been adopted since the original theory (Roussel, 2013). Spradley is one of many that developed a model based on Lewin’s theory. Spradley’s model houses eight steps including: recognize, diagnose, analyze, selection of the change, planning of the change, implementation of the change, evaluation of the change, and stabilization of the change (Roussel, 2013). Spradley is only one creator of a change model, and regardless of the model used, evidence-based theory is necessary for change to occur and be successful. Nurse leaders are in the position to not only promote change, but to also ensure it occurs in an effective manner.

Summary

Healthcare is changing drastically and the call for nursing professionals is increasing every day. It is imperative that Nurse leaders advocate for the necessary change, support nursing staff, and enhance the profession in its entirety. The two key programs present in the new healthcare initiatives discussed are AIM and PCMH. These programs support the needs of the population especially those with advanced illnesses. Nurse leaders need to assist in the education of multiple disciplines in healthcare to ensure that equal, quality care is provided to the entire population. In order to be effective in the education process as well as supporting the vast healthcare changes, Nurse leaders must fully understand the changes and the available programs for not only patients, but staff development as well. Nurse leaders can accomplish these tasks through utilizing evidence-based research and becoming part of committees that inform about the change and support the advanced illness population.

Quality care will remain a focus in the future, especially with the healthcare changes and initiatives that are being implemented. Caring is a core principle in the nursing profession and should remain the same, even in light of new challenges. Nursing professionals have an opportunity to become part of the change and the associated quality improvement measurements that are current as well as those of the future. Advocacy for patient care and the nursing profession must always remain on the forefront when participating in healthcare change. Nurse leaders will become key in transforming healthcare and must be knowledgeable and prepared to ensure that the core principles are not lost.

References

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Berenson, J., Doty, M. M., Abrams, M. K., & Shih, A. (2012). Achieving better quality of care for low-income populations: The role of health insurance and the medical home for reducing health inequities. The Commonwealth Fund 1600(11), 1-18.

Dorman-Marek, K., Stetzer, F., Ryan, P. A., Denison-Bub, L., Adams, S. J., Schlidt, A., & ... O'Brien, A. (2013). Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication. Nursing Research, 62(4), 269-278. doi:10.1097/NNR.0b013e318298aa55

Marshall, E. S. (2011). Transformational leadership in nursing: From expert clinician to influential leader. New York: Springer Publishing Company.

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National Committee for Quality Assurance. (2013). Patient-centered medical homes – Fact Sheet. Retrieved from

Potera, C. (2012). Dignity-Driven Decision Making Improves Advanced-Illness Care. American Journal of Nursing, 112(9), 16.

Reid, R. J., Coleman, K., Johnson, E. A., Fishman, P. A., Hsu, C., Soman, M. P., Trescott, C. E., Erikson, M., & Larson, E. B. (2010). The group health medical home at year two: Cost savings, higher patient satisfaction, and less burnout for providers. Health Affairs 29(5), 835-843. Retrieved from

Roussel, L. (2013). Management and leadership for nurse administrators (6th ed). Burlington, MA: Jones & Bartlett Learning.

Takach, M. (2011). Reinventing Medicaid: State innovations to qualify and pay for patient-centered medical homes show promising results. Health Affairs 30(7), 1325-1334. Retrieved from

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