Enhanced Patient and Caregiver Engagement Drive Utilization and Quality Outcomes in an Advanced Practice Nurse-Led Care Transitions Intervention with Super Utilizers

Background   Care transitions across the health care continuum have been the focus of numerous efforts of health care systems throughout the United States in the last few decades. Poorly managed transitions can result in poor health outcomes and have tremendous financial implications for both patients and healthcare systems. In an effort to address poor transitions in care and minimize waste in the health care system, several approaches to the provision of transitional care have been tested and are still currently underway. Congruent with the triple aim, improving the experience of care, improving the health of populations, and reducing per capita costs of health care, health care facilities, clinicians and patients have been working together to establish effective programming and interventions to improve transitions in care, reduce health care ending and optimize the quality and safety of care provided to patients across the care continuum. Current shortcomings in the U.S. health care system have a profound impact on the chronically ill, who experience repeated changes in health status accompanied by numerous transitions between providers and care settings. The common thread among all of the successful transitional care models has been the presence of nurses, as clinical leaders or care managers. Advanced Practice Nurses possess the clinical and interpersonal skills, in-depth knowledge of systems and how to work within them to affect positive patient outcomes and keep patients well during vulnerable transitions in care.

Objectives To explore the impact of a 90 day Advanced Practice Nurse-led transitional care program, specifically the incorporation of health coaching and the resulting impact on readmissions, cost of care, patient transition skills and quality of life.

Results The intervention population (n = 142, M= 0.59 re-admissions, SD= 0.84) demonstrated a 30% overall reduction in re-admissions compared to the pre-program re-admission population (M= 0.85 re-admissions, SD= 0.47, t (1,136) = -3.82, p= < .001[O1] . The intervention resulted in over a three-fold increase in average transition skills scores, t (1, 136) = 19.20, p < .00001 and 2.5 fold improvement in quality of life among intervention participants t (1, 136) = -11.99, p< .00001). The resulting impact on cost of care was a total reduction in cost of $1,534,330, with an average of $12,276 reduction per participant, t (1, 141) = 3.79, p < .001).

Conclusion   As the health care industry moves forward in pursuit of the best way to provide care for patients across the entire continuum of care, the focus should be on optimizing both utilization and quality of life for the most vulnerable populations through the provision of Advanced Practice Nurse- led transitional care emphasizing health coaching and patient and caregiver engagement. Incorporation of models of care, based in the nursing paradigm, augmented by interdisciplinary collaboration and emphasizing patient engagement through health coaching should be a focus for future research and serve as the basis for transitional care programs nationwide. 

 

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