SE10EO Nurses participate in the assessment and prioritization of the healthcare needs of the community.
Provide one example, with supporting evidence, of an improvement in an identified healthcare need that was associated with nurses' partnership with the community. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
NAME OF INITIATIVE
Nurses Partnering with the Community to Decrease Diabetes Mellitus (DM) Readmission Rates
BACKGROUND/PROBLEM
Diabetes mellitus occurs when the body cannot produce or respond appropriately to insulin and as result of elevated blood glucose levels and other metabolic changes, lead to the development of serious and often disabling complications. Effective therapy can prevent or delay diabetic complications. However, almost 25% of Americans with DM are undiagnosed, and another 57 million Americans have blood glucose levels that greatly increase their risk of developing DM in the next several years. Few people receive effective preventative care, which makes DM an immense and complex public health challenge. It affects an estimated 23.6 million people in the United States and is the 7th leading cause of death. The estimated total financial cost of DM in the US in 2007 was $174 billion, which includes the costs of medical care, disability, and premature death. The rate continues to increase both in the United States and throughout the world.
People from minority populations are more frequently affected with type 2 DM. Minority groups constitute 25% of all adult patients with diabetes in the US and represent the majority of children and adolescents with type 2 DM. Lifestyle change has been proven effective in preventing or delaying the onset of type 2 diabetes in high-risk individuals. (Healthy People 2020; www.healthypeople.gov)
In early 2013, Professional Research Consultant, Inc. in collaboration with The Health Council of South Florida released the results of a county-wide household survey in Miami-Dade County conducted as a follow up to a survey performed in 2010. Analysis of 2012 data from the Florida Agency for Healthcare Administration demonstrated increased burden for a number of prevention quality indicators (e.g. diabetes, hypertension, heart failure) in lower income neighborhoods. The prevalence of DM in Miami-Dade County was reported to be at 10.8% similar to the national and statewide proportion. More specifically in the South Dade Cluster, it was estimated to be 8.6%. There was a positive correlation between diabetes and age as well as gender, race and socioeconomic status. Seniors, women, lower-income residents, Blacks and Hispanics were likely to report being diabetic.
Nurses Participate in the Assessment and Prioritization of Community Healthcare Needs
In the fall of 2012, Homestead Hospital partnered with the Health Council of South Florida to conduct a community health needs assessment in order to identify the top healthcare needs and issues within the community. The Community Health Needs Assessment provided information so that communities may identify issues of greatest concern and decide to commit resources to those areas, thereby making the greatest possible impact on community health status. This Community Health Needs Assessment normally served as a tool toward reaching 3 basic goals:
- To improve residents’ health status, increase their life spans, and elevate their overall quality of life;
- To reduce the health disparities among residents. By gathering demographic information along with health status and behavior data, it would be possible to identify population segments that were most at-risk for various diseases and injuries. Intervention plans aimed at targeting these individuals may then be developed to combat some of the socio-economic factors which have historically had a negative impact on residents’ health;
- To increase accessibility to preventive services for all community residents. More accessible preventive services would prove beneficial in accomplishing the first goal described above as well as lowering the costs associated with caring for late-stage diseases resulting from a lack of preventive care.
The assessment was conducted through focus group with residents, healthcare experts, advocates and Homestead Hospital leaders. The nurses that participated in this assessment were Chief Nursing Officer and Vice President Gail Gordon, RN, Assistant Vice Presidents of Nursing Ann Marie Allen, RN and Ana Cabrera, ARNP.
Once the data was analyzed, several categories were presented to the participants. Each select group was asked to rate the top priorities based on their knowledge, expertise and experience. Listed below were the results of the top priorities as rated by each group:
Top Priorities |
Baptist Health South Florida (BHSF) Leaders |
Homestead Hospital Leaders |
Community Health Focus Group |
1 |
Availability of Preventative/ Primary Care |
Access to Care (uninsured) |
Access to Care (uninsured) |
2 |
Access to Care (uninsured) |
Chronic Disease Management |
Chronic Disease Management |
3 |
Chronic Disease Management |
Availability of Preventative/ Primary Care |
Maternal and Child Health |
4 |
Healthy Lifestyles: Exercise/ Nutrition |
Healthy Lifestyles: Exercise/ Nutrition |
Communicable Diseases (STD/ HIV) |
5 |
Cancer Prevention/ Treatment |
Socioeconomic Challenges |
Mental Health/ Substance Abuse Treatment |
Identified Healthcare Need
The information received from the above participants with their rated priorities was compiled to identify the top healthcare needs and issues in the community. Based on the input of BHSF, Homestead Hospital leaders and community health focus group, the top priorities were identified and ranked accordingly as follows: (SE10EO 01 Community Health Needs Assessment)
- Access to care (Adults with Health Insurance, Children with Health Insurance, Medicaid Enrollment)
- Availability of primary and preventative care (Adults with a Primary Care Provider, Annual Medical Checkups, Primary Care Physicians)
- Chronic disease management (Diabetes, Adult Asthma, COPD Hospitalizations, Teen Asthma, Heart Disease, Stroke, Heart Failure, High Blood Pressure)
- Maternal and child health
- Socioeconomic issues.
Specifically looking at chronic disease management, the distribution of hospital visits for diabetes by residential zip code in the Homestead Hospital service area was more than 50% higher than the county wide rate, at 43 per 10,000 compared to 25 per 10,0000 residents, respectively. As stated earlier, socioeconomic conditions and certain ethnicities, which are common in the community, place our patients at greater risk of diabetes and its potential serious complications.
GOAL STATEMENT(S)
The Nurse Governance Council (NGC), which served to oversee the implementation of professional nursing practice throughout the organization, formulated the FY 13 nursing strategic goal and included decreasing diabetes readmissions as one of the targets. At the end of FY 12, the average DM readmission was 16.5%. The goal was to reduce 30-day DM readmissions, from all payers, by 3% (from 16.5% to 13.5%).
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY(IES)
NGC oversaw the development of Nursing Service Department’s strategic goal. NGC conducted annual retreats participated in by nursing leaders, patient care supervisors, clinical nurse educators and clinical nurses to afford input into goal setting by nurses across all levels. In October 2012, the group reviewed the 30-day DM readmission data for FY 2012 and identified an improvement opportunity. During the discussions that ensued, the council noted challenges with follow up and care coordination upon DM patient discharge. The majority of these patients in the community were uninsured, with no access to primary care and resources to obtain medications and supplies. These factors contributed to high DM readmissions in Homestead Hospital. The group decided to include this in the FY 13 nursing strategic goal, which was aligned to the community health needs assessment’s third priority – chronic disease management.
Cognizant of DM prevalence in the community, Homestead Hospital had a full time Diabetes Nurse Educator Elva Diaz, RN who assisted in the care of inpatient diabetic patients. Her primary responsibilities included DM education to patients, community and staff. Medical staff consulted Diaz for diabetic education of newly diagnosed and uncontrolled diabetic patients. Nurses also sent her referrals to evaluate and educate diabetic patients. During the course of seeing patients, Diaz provided medication dosage recommendations to medical staff and education (formal and informal) to the nursing staff. Diaz also spearheaded hospital-wide initiatives addressing inpatient blood sugar management.
Nurses Partnership with the Community
Homestead Hospital, through its parent entity, BHSF, directly funds the operations of local clinics that provide healthcare to uninsured members of the South Florida community. Baptist Health subsidizes 4 clinics: Good Health Clinic, Good News Care Center, Open Door Health Center and South Miami Children’s Clinic. Two of the 4 clinics are located in Homestead Hospital’s primary service area. In some instances, BHSF’s contribution amounts to more than half of the operational budget of the clinic. In 2013, Baptist Health’s combined contribution exceeded $2 million, enabling these clinics to handle more than 15,000 patient visits. More specifically, the Good News Health Clinic received $802,000 per year and Open Door Health Clinic received $550,000 per year with nearly $500,000 in in-kind services such as diagnostic testing and pharmaceuticals. Recognizing the great need for healthcare access, particularly within the Deep South portion of Miami-Dade County, and recognizing that many individuals, such as undocumented residents, will continue to remain ineligible for federal healthcare subsidies, BHSF continued committing additional resources to existing providers to improve access to care for the uninsured. These community clinics have needs beyond just funding their continuing operations. They need partners to donate medical supplies and pharmaceuticals and to provide follow-up services, such as advanced diagnostic testing and surgery, to treat the patients’ conditions and prevent them from worsening.
As the only hospital within an 18-mile radius, Homestead Hospital’s partnership with local caregivers was critical. In an effort to enhance access to and continuum of care, Homestead Hospital convened key community partners. Local providers and community clinic leaders regularly meet to share experiences and discuss opportunities for improvement in streamlining referrals and operational efficiencies. Assistant Vice Presidents of Nursing Ana Cabrera, ARNP and Ann Marie Allen, RN, Nurse Practitioner Adaeze Ohaeto, ARNP and Diaz participated in these dialogues. This ongoing communication helps mitigate any barriers preventing individuals from achieving optimum outcomes by improving their access to preventive and primary care offered at these community clinics.
The community clinics shared that they were operating above capacity. The wait time for an appointment for a new patient was 6 weeks. Knowing that post-discharge visits were integral to reducing readmissions, Homestead Hospital embarked on a project to open a “gap” clinic. After several discussions and proposals that included the local clinics and BHSF at the corporate level, Homestead Hospital was able to facilitate the opening of a transitional primary care center - Baptist Health Follow-up Care - in March 2012. Cabrera and Allen oversaw the planning and opening of the clinic. Ohaeto managed it. The clinic was also supported by a registration clerk, social worker and clinical nurse educator. The key concept was to bridge patients to a permanent medical home. This required a very tightly knit, well-defined and collaborative relationship with local healthcare organizations, primary care physicians (PCP) and specialists within the community. The initial focus was on diabetic and heart failure patients. The social worker from the clinic made rounds at the hospital to capture patients that needed follow-up care immediately after discharge. Initially, all diabetic and heart failure patients were being directed to the clinic. However, due to contracts with insurance companies, insured patients were only permitted to visit the clinic if their primary care provider did not provide them with an appointment within 72 hours after discharge. As a result, patients with other chronic diseases who lacked primary care were added to the group of patients being referred to the clinic.
In addition to her responsibilities in coordinating care of inpatient DM patients, Diaz also became Homestead Hospital’s liaison and advocate for community DM patients. She referred unfunded DM patients, particularly those who were newly diagnosed or with poorly controlled blood sugar, to the Good News Care Center for post-hospitalization follow-up. She also collaborated with Case Management and Pharmacy to provide 30-day supply of medications through the hospital’s Compassionate Care Program (CCP). In January 2013, she contacted an insulin pharmaceutical sales representative to discuss how they could assist in providing medications to the uninsured diabetic population. During this meeting, she obtained information on a patient drug assistance program and the pharmaceutical company’s website which offered free samples of their insulin, needles, syringes and educational materials that could be reordered every 2 weeks. Diaz also received interactive education materials and discount coupon cards for the insured patients to take to their pharmacy of choice. The discount card would take $50.00 off the first co-pay and $25.00 off the rest of the refills for one year. She provided the free supplies and vouchers to DM patients upon discharge. This ensured that DM patients could continue with their medication regimen until their first scheduled clinic visit. This further helped address one of the barriers – lack of resources to obtain DM medications and supplies.
In her efforts to increase community education, also in January 2013, Diaz coordinated a team of clinical nurses to assist in manning a table during the Homestead Hospital annual community health fair. This fair provided free blood sugar screenings and was attended by approximately 250 people. Diaz and her team provided one-on-one DM education and handed out educational materials, plates with appropriate portion sizes and monthly diabetes support group information. Diaz facilitated free monthly support group meetings for DM patients held at the Homestead Hospital campus.
In February 2013, Diaz met with another pharmaceutical representative who provided her with insulin vouchers, supplies, insulin starter kits, education materials, discharge booklets (in English and Spanish) and cookbooks. Through the relationships she has established, she was able to obtain free supplies, materials and vouchers on a monthly basis which she passed along to the patients.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
|
Gail Gordon, MSN, RN, NEA-BC |
CNO and Vice President |
Administration |
Participated in community health needs assessment |
|
Ann Marie Allen, MSN/ MSHA, RN, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Participated in community health needs assessment |
|
Ana Cabrera, DNP, ACNP-BC, NEA-BC |
Assistant Vice President of Nursing |
Nursing Administration |
Participated in community health needs assessment |
|
Elva Diaz, BSN, RN, CDE |
Diabetes Nurse Educator |
Diabetes |
Provided DM patient education; acted as hospital community liaison for DM patients |
|
Adaeze Ohaeto, DNP, ACNP-BC |
Nurse Practitioner |
Baptist Health Follow-up Care |
Managed daily operations at Baptist Health Follow-up Care clinic |
|
Ana Lopez |
Director |
Good News Clinic |
Liaison between hospital and Baptist Health Follow-up Care clinic |
|
Vilma Fadhel |
Social Worker |
Baptist Health Follow-up Care |
Liaison between hospital and Baptist Health Follow-up Care clinic |
|
Cary Acosta |
Social Worker |
Baptist Health Follow-up Care |
Liaison between hospital and Baptist Health Follow-up Care clinic |
|
Jackie LeBoeuf, MBA |
Director Administrative Project |
Administration |
Assisted in demographic research, planning and grant applications |
|
OUTCOMES
In the first quarter of 2013, a review of DM readmission data provided interesting results that inspired a further drill down that ultimately highlighted an effective, essential partnership between a community clinic and the nursing staff. While the readmission rates for DM continued to be alarming in Deep South Dade and inherently Homestead Hospital, the team felt a bit disheartened that their efforts were not reflected in an improved DM readmission rate. Mindful of the community’s demographics, they decided to run the readmission data by payer. Interestingly, they learned the following:
- Insured patients represented 20% of the total DM hospital readmissions. These patients were treated at Homestead Hospital and discharged to their PCPs.
- Uninsured patients represented only 5.75% of the total DM hospital readmissions.
The lower readmission rate for the uninsured patients is directly related to the transitional care model we have in place for the most vulnerable patients. These patients visit with the Diabetes Nurse Educator while at Homestead Hospital and they are referred to the Baptist Health Follow-up Care for medication titration, disease education, and assistance with socioeconomic barriers. Then the patients are transitioned to one of the community clinics (e.g. Good News Care Center), where they would have a permanent medical home. During the calendar year of 2013, Diaz, during her visits with hospitalized patients, identified and referred over 200 patients to the Good News Care Center. This accounted for about 25% of the total hospitalized patients that were referred to and seen by Diaz. As a result, these clinic patients sought and received follow-up care and diagnostics at Homestead Hospital over 1,200 times. The cost of this free care amounted to over $400,000.
Exhibit SE10EOa: Homestead Hospital 30-Day Readmission Rate (All Payers)
Analysis: NGC met its goal of decreasing DM readmission among all payers by 3% as evidenced by 3 consecutive post-intervention data points below the goal line and decreasing calculated trend line.
Summary Attachments/Hyperlinks/Evidences
SE10EO 01 Community Health Needs Assessment
Exhibit SE10EOa: Homestead Hospital 30-Day Readmission Rate (All Payers)