Objective: To examine the reasons for the effectiveness of a model of APN transitional care (discharge planning and home follow-up) by analyzing patient problems, APN interventions, APN time and number of patient contacts with patient outcomes and health care costs in 5 high-risk, high cost patient groups.
Design: Analysis of 333 interaction logs created by APNs during 5 randomized controlled trials testing the effects of APN transitional care on patient outcomes and health care costs. The interaction logs contained data describing each patient contact, including date, duration in minutes, type of contact (hospital, home, clinic, or telephone), who initiated the contact (patient or APN), most recent hospitalization admission and discharge dates, and most recent acute care visit.
Population, Sample, Setting, Years: Participants in the treatment groups of 5 randomized controlled trials: very low birth weight infants (n=39); women with cesarean birth (n=61), high risk pregnancy (n=44), and hysterectomy surgery (n=53); and elders with cardiac medical and surgical diagnoses (n=139).
Concepts or Variables Studied: Patient problems, APN interventions, APN time, number of APN contacts with patients, group-specific patient outcomes, and health care costs
Methods: Logs containing recordings of all APN interventions with intervention subjects, APN time and type of patient contact were content analyzed with the smallest phrase or sentence as the unit of analysis. These units were then classified using the Omaha Classification System to determine patient problems and APN interventions. Units within each visit were characterized by domain, problem, intervention category, and intervention target. Interrater reliability was maintained at 80% or greater throughout the study.
Findings: Groups with greater mean APN time and contacts per patient demonstrated greater improvements in patient outcomes and greater health care cost savings. In the elder group with the least APN time and contacts (all by telephone and for only 2 weeks post-discharge) improved patient outcomes were only possible for 6 weeks post-discharge and only in the medical cardiac group. The high-risk pregnancy group followed antenatally through 8 weeks postpartum had higher APN time and contacts and demonstrated a much larger reduction in hospital charges and greater improvements in patient outcomes. Of the 150,131 APN interventions, surveillance was the predominant APN function in all 5 patient groups. Health teaching, guidance, and counseling was the second most frequent APN intervention in 4 of the 5 patient groups. In 4 of the 5 patient groups, case management was the third most frequent APN intervention, reflecting the complexity of care needed by these high risk and vulnerable patient groups. In all five groups, treatments and procedures accounted for <1% of total APN interventions. Distribution of patient problems (N=150,131) differed across groups reflecting the health care problems common to the group. In the three women’s groups (cesarean birth, high-risk pregnancy, and hysterectomy), the largest percentage of patient problems were in the physiologic domain. In two of the three groups with newborns, the psychosocial problems of caretaking/parenting and issues of growth and development were paramount. In the elder group, health-related behavior problems predominated, reflecting the focus of treatment after a cardiac event.
Conclusions: Dose of APN time and contacts makes a difference in improving patient outcomes and reducing health care costs. Skills needed by APNs in providing transitional care include well-developed skills in assessment, teaching, counseling, communication, collaboration, health behaviors, negotiating systems, and condition-specific knowledge since patient problems differ among patient groups. The differing profile of patient problems underscores the importance of matching APN clinical specialization with the patient group wherever possible to realize optimal outcomes. The APN’s in-depth knowledge in a specialty area likely allows them to make the most reasoned, effective and appropriate decisions that result in improved patient outcomes and reduced health care costs.
Implications: Making a difference in patient outcomes and reducing health care costs requires highly-skilled nurses who are knowledgeable about the group of patients under their care and a sufficient amount of time and contact with these patients.
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