Applying the Evidence to Clinical Practice: Utilizing an Advanced Practice Nurse-Led Transitional Care Model to Improve Health Outcomes of High Risk Elders with Heart Failure Living at Home

Tuesday, 19 November 2013: 9:10 AM

Linda Lazzaro Steeg, DNP, RN, MS, APRN-BC
School of Nursing, State University of New York at Buffalo, Buffalo, NY

Learning Objective 1: The learner will be able to identify six clinical practice elements defined by ACCF/AHA 2009 Clinical Practice Guidelines for the Management of Heart Failure.

Learning Objective 2: The learner will be able to evaluate if care delivered by the APRN to Elders with Heart Failure addressed Omaha’s Four Clinical Practice Categories.

Background: In 2007, the Center for Medicare/Medicaid Services (CMS) estimated expenditures of $15 billion dollars for Medicare beneficiaries on “churning”, a term used to describe the movement of vulnerable elders from hospital to community and back again. Further, CMS estimates that 76% of these readmissions to hospitals were preventable, noting that 64% of those readmitted had received no post-discharge community follow-up. Various models of transitional care have evolved as initiatives which address the quantitative and qualitative costs of churning. The Transitional Care Model(TCM), developed by Naylor and colleagues, utilizes Masters prepared Advanced Practice Nurses (APRNs) whose expertise matches the needs of the specific vulnerable population for whom they are providing care, for example, elders with Heart Failure.

Methods: This descriptive study evaluated care delivered by APRNs to elders with Heart Failure residing at home. Retrospective chart reviews of a convenience sample (n=15) were completed. The six clinical elements defined by the ACCF/AHA 2009 Clinical Practice Guidelines(CPGs) for the Management of Heart Failure and  four Clinical Practice Categories of The Omaha Classification System were used as criteria against which to evaluate the care delivered. Additionally, readmissions and frequency of visits to the Emergency Department were evaluated at 30, 60 and 90 days.

Results: This study demonstrated that care delivered by the APRNs was consistent with 2009 ACCF/AHA CPG’s for the Management of Heart Failure.  Further, care delivered by the APRNs addressed the Clinical Practice Categories. Evidence of medication reconciliation and ongoing medication decision making was demonstrated for the 15 cases across the 12 months of the study. Additionally, care delivered by the APRNs was effective in eliminating readmissions at 30,60 and 90 days and decreasing visits to the Emergency Department at 30, 60 and 90 days, furhter supporting the APRNs' abilities to keep people well across time.