evidenced-based practice for the nurse care manager

Evidenced-based Practice for the Nurse Care

ManagerTelana Fairchild, Erica Magaziner, Zofia Stec, Ashley RosatiNurse Practitioner StudentsUMass - Worcester, Graduate School of NursingN/NG 603BApril 23, 2013

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Care Managers• Provide direct patient care by:

Coordinating care Helping patients navigate the

system Improving access for patients Communicating across the

care team Deliver patient-centered

careApril 23, 2013EBP for NCM2

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Direct role in patient care• Provide patient education and

training in self-management skills• Coordinate care with

specialists/clinicians• Connect patients with community

resources and social services.

EBP for NCM3 April 23, 2013

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Care manager vs.

• Help practices organize & prioritize quality improvement (QI) activities

• Train staff to understand & use QI data effectively

• Promote effective communication among practice staff

Case manager

• Assess and regularly reassess patients’ care needs

• Develop, reinforce, & monitor care plans

• Provide education & encourage self-management

• Communicate info across clinicians

• Connect pts to community resources & social services

EBP for NCM4 April 23, 2013

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Care Managers: Evidenced-Based Practice

Nurse Care Manager Contribution to Quality of Care

Objective: Review details of the CCMs’ assessments and interventions related to six geriatric conditions compared with PCP care provided to the same patients in a community.• Study cohort: 231 patients 65 and older enrolled in the SNP

for at least 13 continuous months.• Areas that improved with CCMs:

Falls- increased % of patients questioned about occurrence of falls and counseled regarding home safety

Dementia- Increased % of cognitive assessment, use of standardized tools, functional and level of social support assessments

Depression- Assessment of affect using standardized tools End-of-life Care

April 23, 2013EBP for NCM5

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Nurse Care Manager Contribution to Quality of Care

• Conclusion: Nurse care managers are valuable resources, skilled at complex psychosocial assessments and behavioral interventions essential to address the needs of older, vulnerable adults in the community. April 23, 2013EBP for NCM6

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Evaluation of care managers in primary care

Objective: to determine the effect of primary care-based care management initiative on residential care placement and death in a population of frail older adults referred for needs assessment in New ZealandDesign/Participants: RCT with a sample of 351 individuals assessed as being at risk for permanent residential care placementInterventions: Care management program consisting of a professional care managers aligned with a family physicianMeasurements: Rates of permanent residential care placement and mortalityResults: Risk of permanent residential care placement or death: control group 0.36 care management initiative group 0.26 (absolute risk reduction 10.2%)Conclusion: Family physician-aligned community care management approach reduces frail older adults’ risk of mortality and permanent residential care placement.


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Care Managers: Evidenced-Based PracticeBarriers and facilitators of

treatment for depression in a Latino community

Themes, categories & concepts:• Social connection &

engagement Social partnership (highly

valued) Personal contact (home

visits desirable method of contact)

Contact failures (Lack of timely access to care)

• Language Interpreters (lack of

communication about the need for interpreters)

• Information Lack of information Need for education Suggestions about community

resources• Regarding care management

Initial care management contact should be face-to-face

Participants viewed care coordination as positive

Viewed communication among HCPs for the purposes of care coordination positively.


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Care managers to improve treatment of depression among Latinos with diabetes

Objective: to assess feasibility and cost of integrating diabetes and depression care management in community clinics serving low-income Latino populationsDesign & Methods: depression care management provided to diabetic patients who screened positive for depressive symptoms. Changes in depressive symptoms measured using PHQ-9, diabetes self-care activities & costsResults: PHQ-9 scored declined 7.9 points (P<0.001). Costs estimated $512 per participantConclusions: adding a depression care manager to an existing diabetes management team was effective at reducing depressive symptoms at a reasonable cost


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Addressing the Problem • Studies have shown

that 40-80 percent of the medical information patients receive is forgotten immediately and nearly half of the information retained is incorrect.


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Health Literacy….the ability to read, understand,

and use health information to make appropriate healthcare decisions and follow instructions for treatment.

AMA & AMA Foundation, 2003

People with low literacy have 30-70 % increased risk of hospitalization


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Teach-Back Method• Asking patients to repeat in their own

words what they need to know or do, in a non-shaming way.

• Not a test of the patient, but of how well you explained a concept.

• A chance to check for understanding and, if necessary, re-teach the information.

• Use with everyone: Use teach-back when you think the person understands and when you think someone is struggling with your directions.


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Teach-Back Method• This technique creates the opportunity for

dialogue in which the clinician provides information, then encourages the patient to respond and confirm understanding before adding new information.

• Re-phrase if a patient is not able to repeat the information accurately.

• Ask the patient to teach back the information again, using their own words, until you are comfortable they really understand it.


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Why Use Teach-Back?• Helps us close the loop between patient

education and patient understanding.• Helps us identify people who do not

understand and creates an additional teachable moment where we can reinforce the information.


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Why Use Teach-Back?• Prevents chronic illness symptoms

from worsening• Prevents re-admissions• Prevents patient medication errors• Improves compliance with

preventative care; immunizations, screenings, appointments

• Improves healthcare costsApril 23, 2013EBP for NCM16

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Common Topics for Teach-Back • Insulin injections• Use of Inhaler• Medication

changes• Diet changes• Tracking daily

weights• Chronic disease

self careApril 23, 2013EBP for NCM17

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How to use Teach-Back• “I want to be sure I explained everything

clearly. Can you please explain it back to me in your own words so I can be sure I did?”

• “What will you tell your husband about the changes we made to your diabetes medicines today?”

• “We’ve gone over a lot of information, a lot of things you can do to get more exercise in your day. In your own words, please review what we talked about. How will you make it work at home?”April 23, 2013EBP for NCM18

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How to use Teach-BackKey Points:• Do not ask yes/no questions like:

“Do you understand?” “Do you have any questions?”

• When teaching more than one concept: “Chunk and Check”

Teach the 2-3 main points for the first concept and check for understanding using teach-back, then go to the next concept


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Motivational Interviewing (MI)• Introduced in 1983 by William Miller• Evidenced- based counseling method for

promoting change and improving adherence to treatment recommendations

• Directive, patient - centered counseling style for eliciting behavioral change by helping patients to explore and resolve ambivalence

• Derived from Prochaska and DiClemente’s transtheoretical model of change


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Motivational Interviewing (MI)• Grounded in assumptions that struggles

with ambivalence are normal part of the process of change and that patients’ motivation and readiness to change are not static traits, but rather dynamic traits that can be greatly influenced by interactions between provider and patient

• Orients the provider to understanding the patient’s level of readiness to change , provider works with patients “where they’re at” in terms of readiness for change, therefore promoting collaboration and reducing resistance


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Motivational Interviewing• Assumes patients progress through stages of change,

experiencing: Normal fluctuations in ambivalence Problem recognition Willingness to take action Most patients will relapse and progress through the

stages several times before successfully maintaining a behavioral change

• Provider acknowledges and respects patient autonomy, recognizing it’s the patients decision to change

• Provider is empathetic and supportive, directive in moving patient toward change by strengthening patient’s own reasons for change


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Motivational Interviewing• Not a “fixed method” in which the provider says

“ I have what you need”, but rather an “evocative method” in which the provider says “ You have what you need”

• Initially adopted for the treatment of addictions, motivational interviewing has been widely adopted to facilitate change across a range of patients health behaviors, including those related to management and prevention of chronic diseases

• A metaanalysis by Rubak and colleagues found that motivational interviewing outperforms traditional advice giving in the treatment of a broad range of behavioral problems and diseases


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Four Principles of MI• Express empathy – the provider communicates that

he/she understands and accepts the patient’s experience, including the patient’s ambivalence about change

• Develop a discrepancy – provider helps patient to become aware of discrepancies between current behaviors and patient’s personal goals and values

• Roll with resistance - arguing is avoided and attempts are made to thoroughly understand patient’s reluctance to change. The goal is to increase intrinsic motivation for change : “ I will change because I want to”.

• Support self-efficacy - potential solutions are elicited from patients rather than prescribed; empowerment and offering choices are critical to the development of patient self-efficacy. Set realistic goals to increase chance of success.


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Four Skills of MI

• Reflective listening

• Asking open-ended questions

• Affirming

• Summarizing


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Skills of MI: Reflective Listening

• Responding to a patient’s statement by stating back the essence or a specific aspect of the statement Ensures that what the provider

thinks the patient means is accurate Diminishes patient’s resistance Encourages further discussion of

patient’s reasons for wanting to make changes


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Skills of MI: Asking open questions

• Elicits discussion of the reasons for making desired change Provider stays away from closed questions that

invite brief “yes” or “no” answers Provider asks open questions whose answers are

reasons that the change is necessary or desirable “What would have to happen for it to become much

more important for you to exercise?” “What worries you about diabetes?” “If you were to stop smoking, what would it be like?” “What are the worst things that might happen if you

don’t take this medication?”April 23, 2013EBP for NCM28

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Skills of MI: Affirming• Express agreement with and/or

commitment patient has to changed behavior Complimenting the patient for making an

effort, “Thanks for coming in today.” Acknowledging small successes, “It’s

great that you were able to take your medication almost every day this week.”

Stating understanding, “I appreciate that you were so honest with me by telling me you haven’t taken your medication this week.” April 23, 2013EBP for NCM29

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Skills of MI: Summarizing• In a few brief statements, summarize what

the patient has said about making a change, followed by open-ended question Link and reinforce material that has been

discussed Always end with: What else?

“Having high blood pressure really scares you, and it is hard to hear that you are at risk for a heart attack or stroke. On the other hand, you’re young, you enjoy eating what you like, and the long term consequences seem far away. What else?”


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Spirit of MI• Collaborate and empower the patient• Respect patient autonomy and

problem solving capability• Develop intrinsic motivation by

eliciting change talk from the patient regarding the target behavior and change behavior

• “Dual expertise”April 23, 2013EBP for NCM31

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Providing Information to Patients

• An “ask-provide-ask-formula” is used First, the provider asks the patient what

she/he knows about the topic that the provider would like to discuss

• Next, the provider asks for permission to advise.

• It is best to ask permission to educate or advise after you have elicited patient’s own thought and feelings about the topic


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Providing Information to Patients

• When advising patients, substitute “ I think” and “You should” with phrases that empower patients by allowing for personal choice, such as “One option you might consider … “ or “ Perhaps you could start with”

• Deliver information in the third person. Rather than “I recommend,” with “Some of my patients have found…” April 23, 2013EBP for NCM33

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Asthma and Diabetes Management and Education• Improving patients’ understanding of

their condition can help them feel more in control of their illness and increase adherence to a management program.

• Work to self empower patients by encouraging self monitoring and recording of symptoms, exacerbations, triggers, and medication management.


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Asthma and Diabetes Management and

Education• Create an education program tailored to the needs of the patient.

• Start by helping patients identify problem areas that impede their ability to manage their asthma independently, such as: Lack of resources (lack of funding, access

to care) Feelings of loss of control over their

symptoms Education level Language barriers April 23, 2013EBP for NCM37

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Asthma Management and Education

• Delivery of Information Utilize interactive and non-interactive

methods of information deliveryInteractive including: audio and visual

presentations on asthma management, technique demonstration of inhaler use, practicing skills, and open discussion with a provider.

Non-interactive including: giving written materials on asthma management education for the patient to utilize independently, without the provider present.


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• The AIR/Kaiser Adult Asthma Program outlines four major focal points for asthma education in their asthma management program. This includes: Introduction to asthma (understanding the illness,

symptoms, etiology, and prevention of complications)

Understanding medications (proper use of inhalers, medication schedules, what the medications do, overuse of medications/proper use of medications)

Prevention and Avoidance (recognizing triggers/preventing triggers)

Management of symptoms (smoking cessation, overcoming barriers to treatment, recognizing the need for medical attention).


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• Smoking Cessation Resources for Patients CDC “I’m Ready To Quit”

http://www.cdc.gov/tobacco/campaign/tips/quit-smoking/

Includes helpful information on how to quit from previous smokers, quitting resources, guides to quitting.

“Smoke Free Texting” – A free an interactive program via texting for smoking cessation. Support is available 24/7.


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Diabetes Management and Education

Prevention is Key• Obese patients with sedentary lifestyles

have the highest risk of developing Type II Diabetes.

• Early recognition and education of at risk patients about increasing daily activity and decreasing intake of fats and carbohydrates can prevent diagnoses or complications.

• The lifetime cost of complications from Diabetes continues to be a major burden on the healthcare system. April 23, 2013EBP for NCM41

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• Assess for compliance at each visit Maintaining a daily

FBS log? Taking medications

correctly? Following an low

sugar ADA diet?


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• Review Diabetes Management each visit Importance of daily BS checks Signs of hypo/hyperglycemia and how

to treat How to draw up and administer insulin Use of oral anti-diabetic medications How to perform skin assessments/foot

assessmentsApril 23, 2013EBP for NCM43

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Safety!

MedicationFalls

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Evidence Based Intervention: Fall Prevention

Get some exercise:• Weak legs increase

risk• USPSTF-moderate

benefit• Also balance training

Walking different ways and directions

Stand to sit• Safetyhttp://www.health.gov/paguidelines/guidelines/default.aspx


http://www.health.gov/paguidelines/guidelines/default.aspx



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Safety in the home:• About 50% of falls• Use checklist

Clutter in walkways

In-reach Grab-bars Non-slip mats Lighting

• Alert System


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• Medication: Review Educate Advocate Use of Vitamin

D• Vision:

Advocate Optometrist Compliance


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Evidence- Based Intervention: Medication Safety

• Problems: Poly-pharmacy Inappropriate use No reviews

• Solutions: Client Info Risk assessment Educate/Review with

Client Interdisciplinary

Review Follow-up Pill box/Education


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References:Agency for Healthcare Research and Quality. (2013). Home Health Nurses and Care Managers Use Software-Aided Medication Review Protocol for Frail, Community-Dwelling Seniors, Leading to More Appropriate Medication Use. Retrieved from http://innovations.ahrq.gov/content.aspx?id=2841#a3Britt, E., Hudson, S. M., & Blampied, N. M. (2004). Motivational interviewing in health settings: a review. Patient Education and Counseling, 53, 147-155. http://dx.doi.org/10.1016/S0738-3991(03)00141-1Caro, J. J., Ward, A. J., & O'Brien, J. A. (2002). Lifetime costs of complications resulting from type 2 diabetes in the U.S. Diabetes Care, 25(3), 476-481. Center for Disease Control and Prevention: National Center for Injury Prevention & Control, Division of

Unintentional Injury Prevention. (2012). Focus on Preventing Falls. Retrieved from http://www.cdc.gov/Features/OlderAmericans/Gibson, P. G., Ram, F. S. F., & Powell, H. (2003). Asthma education. Respiratory Medicine, 97(9), 1036-

1044. doi: 10.1016/S0954-6111(03)00134-3 Gibson, P. G., Powell, H., Coughlan, J., Wilson, A. J., Abramson, M., Haywood, P., . . . Walters, E. H. (2003). Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews (Online), (1)(1), CD001117. doi:10.1002/14651858.CD001117 Gilmer, T., et al. (2008). Improving treatment of depression among Latinos with diabetes using Project

Dulce and IMPACT. Diabetes Care, 31, p. 1324-1326.

http://dx.doi.org/10.1016/S0738-

http://dx.doi.org/10.1016/S0738-

http://www.cdc.gov/Features/OlderAmericans/



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References:Heiges, E. The teach-back method. Retrieved on April 8, 2013 from: http://surroundhealth.net/Topics/Education-and-Learning-approaches/Health-literacy/Articles/The-Teach-Back-Method.aspxKessels, R. (2002). Patients’ memory for medical informationI. Journal of Social Medicine, 96, p.

219-22.Levensky, E. R., Forcehimes, A., O’Donohue, W. T., & Beitz, K. (2007). Motivational interviewing.

An evidence -based approach to counseling helps patients follow treatment recommendations. American Journal of Nursing, 107, 50-58Motivational Interviewing: http://www.motivationalinterview.org/Parsons, M., et al. (2012). Should care managers for older adults be located in primary care? A

randomized controlled trial. Journal of American Geriatrics Society, 60, p. 86-92. doi:10.1111/j.1532-5415.2011.03763.x

Paul, C. L., Piterman, L., Shaw, J., Kirby, C., Sanson-Fisher, R. W., Carey, M. L., . . .Thepwongsa, I. (2013). Diabetes in rural towns: Effectiveness of continuing education and feedback for healthcare providers in altering diabetes outcomes at a population level: Protocol for a cluster randomised controlled trial. Implementation Science : IS, 8, 30-5908-8-30. doi: 10.1186/1748-5908-8-30; 10.1186/1748-5908-8-30

Powell, H., & Gibson, P. G. (2003). Options for self-management education for adults with asthma. Cochrane Database of Systematic Reviews (Online), (1)(1), CD004107.

doi:10.1002/14651858.CD004107


http://surroundhealth.net/Topics/Education-and-Learning-approaches/Health-literacy/Articles/The-Teach-Back-Method.aspx

http://surroundhealth.net/Topics/Education-and-Learning-approaches/Health-literacy/Articles/The-Teach-Back-Method.aspx

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References:Roth, C., et al. (2012). Nurse Care Manager Contribution to Quality of Care in a Dual-Eligible

Special Needs Plan. Journal of Gerontological Nursing, 38 (7), p. 44-54Sanden-Eriksson, B. (2000). Coping with type-2 diabetes: The role of sense of coherence compared with active management. Journal of Advanced Nursing, 31(6), 1393-1397.Tariq, S. H., Karcic, E., Thomas, D. R., Thomson, K., Philpot, C., Chapel, D. L., & Morley, J. E. (2001).

The use of a no-concentrated-sweets diet in the management of type 2 diabetes in nursing homes. Journal of the American Dietetic Association, 101(12), 1463-1466. doi:10.1016/S0002-8223(01)00353-4

Taylor, E., Machta, R., Meyers, D., Genevro, J. & Peikes, D. (2013). Enhancing the primary care team to provide redesigned care: the roles of practice facilitators and care managers. Annals of Family Medicine, 11 (1), p. 80-83. doi:10.1370/afm.1462

Tool 5: The Teach-Back Method - NC Health Literacy. Retrieved On April 9, 2013 from: www.nchealthliteracy.org/toolkit/tool5.pdf

Tuomilehto, J., Lindstrom, J., Eriksson, J. G., Valle, T. T., Hamalainen, H., Ilanne-Parikka, P., . . . Finnish Diabetes Prevention Study Group. (2001). Prevention of type 2 diabetes mellitus by changes in lifestyle among subjects with impaired glucose tolerance. The New England Journal of Medicine, 344(18), 1343-1350.

doi:10.1056/NEJM200105033441801


http://www.nchealthliteracy.org/toolkit/tool5.pdf

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References:Uebelacker, L., et al. (2010). Barriers and facilitators of treatment for depression in a Latino

community: a focus group study. Community Mental Health Journal, 48, p. 114-126. doi:10.1007/s10597-011-9388-7

U.S. Preventive Services Task Force (USPSTF): U.S. Preventive Services Task Force Recommendation Statement. (2012). Prevention of Falls in Community-Dwelling Older Adults. Retrieved from http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htmWelch, G., Rose, G., & Ernst, D. (2006). Motivational interviewing and diabetes: What is it, how is

it used, and does it work. Diabetes Spectrum, 19, 5-10White, M., Garbez, R., Carroll, M., Brinker, E., & Howie-Esquivel, J. (2013). Is "teach-back"

associated with knowledge retention and hospital readmission in hospitalized heart failure patients? Journal of Cardiovascular Nursing, 28 (2), p. 137-146. doi:

10.1097/JCN.0b013e31824987bdWilson, S. R., Scamagas, P., German, D. F., Hughes, G. W., Lulla, S., Coss, S., . . . Stancavage, F.

B. (1993). A controlled trial of two forms of self-management education for adults with asthma. The American Journal of Medicine, 94(6), 564-576.

Wittmeier, K. D., Wicklow, B. A., Sellers, E. A., Griffith, A. T., Dean, H. J., & McGavock, J. M. (2012). Success with lifestyle monotherapy in youth with new-onset type 2 diabetes. Paediatrics & Child Health, 17(3), 129-132.


http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm

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What questions do you have?

53 April 23, 2013EBP for NCM

evidenced-based practice for the nurse care manager

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