Connie White Williams, left, and Maria ShireyThe University of Alabama at Birmingham School of Nursing has received a $1.5 million Nurse Education Practice Quality Retention grant from the Health Resources and Services Administration to open a new nurse-managed, population-based, transitional care clinic for heart-failure patients recently discharged from UAB Hospital.
Born of the UAB Nursing academic practice partnership between the school and hospital, this innovative, replicable, collaborative-practice model clinic comprises an interprofessional team of nursing, medicine, social work, health services administration and health information technology professionals. It targets the underinsured and medically underserved. The three-day-per-week clinic and its around-the-clock transitional care support opened this month on the second floor in UAB Hospital’s Russell Ambulatory Center and fills a gap in the community.
“Recent closure of the regional indigent hospital, Cooper Green Mercy Hospital, has created a critical access issue for this vulnerable population,” said the project’s director Maria Shirey, Ph.D., assistant dean for Clinical and Global Partnerships. “The school already has experience with the successful nurse-managed PATH clinic at M-POWER Ministries, which is geared to people living with diabetes. This new clinic expands our reach, serving as a hub for transitional care coordination services for heart-failure patients across the hospital, clinic, home and community.”
“Imagine being discharged from the hospital knowing you suffer from heart failure and having no access to continuing outpatient care,” said UAB School of Nursing Dean Doreen Harper, Ph.D. “What do you do when you’re in trouble — go to the emergency department, get readmitted or, worse, do nothing? It’s a recipe for a vicious cycle that could have disastrous outcomes. Our partnership with the hospital and our previous success at the PATH clinic will give UAB patients the support they need to hopefully prevent this from happening.”
Effective strategies needed
During the past several years, UAB has been monitoring clinical outcomes in heart-failure patients, says Connie White-Williams, Ph.D., director of the Center for Nursing Excellence and Shirey’s partner in the project. Inconsistent lengths of hospital stays have been observed along with higher-than-desired readmission rates. This, she says, is in line with studies from the American Heart Association’s “Get With the Guidelines” heart-failure registry that suggest 30-day hospital-readmission rates for heart-failure patients have remained steady despite efforts aimed at decreasing them. Traditional quality efforts, she says, have only modestly improved the rates, and further development of new, more effective strategies is needed.
“We believe this model, with its around-the-clock transitional care coordination across the hospital, clinic and home, will be effective in keeping patients at home and as healthy as possible,” White-Williams added. “Given the requirements of the Triple Aim and the value-based purchasing-reimbursement systems that are part of the Affordable Care Act, care-coordination improvement is needed for this patient population. And what we learn from this initiative can ultimately change the existing model of care to benefit all heart-failure patients.”
Transitional care coordination begins while patients are still in the hospital, Shirey says. A clinical nurse leader will serve as a case manager to coordinate care across the health care continuum and be on call for issues that may arise after clinic hours. Nurse practitioners will see patients during clinic hours and make daily inpatient rounds on eligible heart-failure patients at UAB Hospital. Team members will evaluate patients for hospice eligibility and contact them within 48 hours of hospital discharges to ascertain their well-being and confirm scheduled follow-up clinic visits.
“A nurse practitioner will make an initial home visit to assess the patient’s status and social support, as well as other issues that could impact their health, including lack of air conditioning or something as simple as not having a scale on which to weigh,” she said.
Palliative care component
Shirey adds that the population-based transitional care team will use the hospital’s new EMMI Solutions technology, an automated voice-response technology, to set up electronic patient calls to trigger self-reported weigh-ins and provide reminders about appointments and care recommendations. EMMI is already being used at UAB Hospital for other patient populations.
A unique aspect of the clinic, Shirey says, is the incorporation of palliative care services. UAB School of Nursing Marie O’Koren Endowed Chair Marie Bakitas, D.N.Sc., has an internationally recognized, NIH-funded program of research focused on delivering targeted palliative care interventions customized for heart-failure patients and their caregivers. Bakitas will help the team to integrate palliative care principles into all aspects of care to help improve quality of life for both the patients and their families.
As the clinic is part of a world-class academic medical center, it also has an educational component. Graduate nursing students and health systems administration students from the schools of Nursing and Health Professions will be involved in conducting needs-assessments, performing information flow and workflow analyses, ensuring the operability of electronic medical records, and developing and implementing a plan for smooth clinic operations. Eventually, a variety of students will be incorporated as members of the health care team. This includes bachelor’s through doctoral nursing students, bachelor’s-level social work students, and medical residents and fellows in cardiology. They will participate in morning team huddles and afternoon post-conferences and provide input on team functioning at the end of each clinic day.
“As trainees, these students are our next generation of providers, and we want them to learn how to practice in interprofessional collaborative practice models as part of high-functioning teams,” Shirey said. “With faculty mentors, students will be able to work on projects that support the clinic and also allow students to fulfill interprofessional-related course requirements. Ultimately, we envision our students’ also being involved as members of interprofessional teams in the community, tackling the social determinants of health that continue to keep our patient population unhealthy, including lack of education, poor environment and poverty.”
Team members for the clinic also include UAB School of Nursing Assistant Professor Shea Polancich, Ph.D., an expert on quality and safety, and UAB cardiologist Vera Bittner, M.D., the clinic’s collaborating physician.