Nurse-Led Care Coordination in a Transitional Clinic for Uninsured Patients With Diabetes.

PURPOSE/OBJECTIVES: The purpose of this article is to inform the reader of the practice of the registered nurse care coordinator (RNCC) within an interprofessional, nurse-led clinic serving uninsured diabetic patients in a large urban city. This clinic serves as a transitional care clinic, providing integrated diabetes management and assisting patients to establish with other primary care doctors in the community once appropriate. The clinic uses an interprofessional collaborative practice (IPCP) model with the RNCC at the center of patient onboarding, integrated responsive care, and clinic transitioning. PRIMARY PRACTICE SETTING: Interprofessional, nurse-led clinic for uninsured patients with diabetes. FINDINGS/CONCLUSIONS: Interprofessional models of care are strengthened using a specialized care coordinator. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Care coordination is a key component in case management of a population with chronic disease. The RNCC, having specialized clinical expertise, is an essential member of the interdisciplinary team, contributing a wide range of resources to assist patients in achieving successful outcomes managing diabetes. Transitional care coordination, moving from unmanaged to managed diabetes care, is part of a bundled health care process fundamental to this clinic's IPCP model. In a transitional clinic setting, frequent interaction with patients through onboarding, routine check-ins, and warm handoff helps support and empower the patient to be engaged in their personal health care journey.

Value of Using a Structured Improvement Approach: A Dedicated Education Unit Exemplar.

ABSTRACT: Using a structured approach to improvement that integrates methodological frameworks and commonly used improvement tools and techniques allows an improvement team to systematically implement and evaluate an intervention. Authors from one academic medical center will describe our four-step structured improvement approach in the design of a dedicated education unit (DEU) pilot to potentially meet a critical post-COVID-19 workforce need. Using our structured improvement approach, we successfully piloted a DEU with a unit-based clinical educator and 16 nursing students over 26 clinical days and received 13 preintervention surveys from participants. Although the DEU pilot was small with limited data, the structured improvement approach resulted in an organized and systematic way of designing, implementing, and evaluating improvement.

Innovations in Academic/Clinical Partnerships During COVID-19 to Prepare a Ready Nursing Workforce.

Management of the COVID-19 pandemic required healthcare leaders and frontline workers to rapidly innovate and adjust to a new reality that has forever transformed nursing education and practice. Throughout the pandemic, key stakeholders in Alabama lobbied for transformations in clinical training practice that ultimately improved students' exposure to clinical environments and alleviated the pressure on practicing nurses and other healthcare workers during pandemic hospitalization surges. The present article highlights the key partners and regulatory innovations that led to these successes in Alabama.

Diabetes Distress in Uninsured Patients with Diabetes During COVID-19 Pandemic: A Longitudinal Observational Study.

This study assessed diabetes distress (DD) and glycemic control levels through three time periods during the COVID-19 pandemic in uninsured patients with diabetes. Diabetes Distress Screening Scales 2 and 17 were utilized to identify the prevalence of DD among uninsured patients during multiple stages of the COVID-19 pandemic at the Providing Access to Healthcare (PATH) diabetes clinic at the University of Alabama at Birmingham. For the 328 uninsured diabetic patients who were screened for DD at least once, the mean age was 46 years old with a majority being Black (55.5%), male (56.1%), and non-Hispanic (89.9%). Mean scores reflecting patients' level of DD initially increased in the first 6 months of the pandemic, from 2.86 to 3.44, and then decreased after 12 months of the COVID-19 pandemic to 3.09, while their mean hemoglobin A1c (HbA1c) followed a similar pattern of initial increase (from 11.31 to 12.13) followed by a decline (to 10.79). Addressing patient concerns quickly through early interventions to provide alternative means of care through telehealth and accommodating safe pick-up of diabetes supplies and medications, including insulin, can reduce DD and contribute to better management of glycemic control. Understanding the potential direct correlation of DD with HbA1c in uninsured patients with diabetes is an important factor for clinicians when providing care to this vulnerable population.

Early detection of obstructive sleep apnea in patients with atrial fibrillation.

BACKGROUND: Obstructive sleep apnea (OSA) is an independent and modifiable risk factor for atrial fibrillation (AF) and correlates with a three-fold higher risk of incident AF. Although OSA is prevalent in patients with AF, it remains underdiagnosed. Guidelines for OSA screening are ambiguous. LOCAL PROBLEM: A small community hospital in the southeast United States lacked standardized OSA screening and consistent sleep clinic referral for hospitalized patients with AF. METHODS: Over 3 months, an OSA bundle (including screening, education, and referral) was implemented for hospitalized patients with AF. A retrospective electronic health record (EHR) review established a baseline comparison group. Descriptive analyses between the intervention and comparison groups evaluated the effectiveness of the OSA bundle. INTERVENTIONS: Eligible patients received OSA screening with the STOP-Bang questionnaire. A STOP-Bang score of 3 or higher triggered patient education about the arrhythmogenic relationship of OSA and AF. At discharge, patients received an ambulatory sleep clinic referral. After 3 months, an EHR review assessed the rate of sleep clinic follow-up, sleep testing, OSA diagnosis, and initiation of positive airway pressure. RESULTS: Of the 68 patients in the comparison group and 33 patients in the intervention group, the rate of OSA screening increased from 4.4% to 100%. Sleep clinic referral increased from 66.7% to 93.5%. Sleep clinic follow-up increased from 0% to 10%. CONCLUSION: Screening for OSA and sleep clinic referral improved with the OSA bundle; however, sleep clinic follow-up remained low. Further quantitative and qualitative investigation is needed to better understand barriers to sleep clinic follow-up.

Telehealth Mental Health Clinical Experience for Prelicensure Nursing Students During COVID-19.

BACKGROUND: The use of an innovative approach for mental health interviews met unprecedented needs during the coronavirus disease 2019 pandemic for patients and staff at a community health clinic and provided nursing students with a telehealth activity that met patient care education requirements while practicing essential skills. METHOD: The nursing students and instructors worked collaboratively with the clinical team to call patients using an algorithm that incorporates screeners for depression, anxiety, and chronic disease distress. RESULTS: Reports during daily debriefings and feedback obtained from evaluations were summarized by faculty and used to improve the activity. These reports indicated the experience was beneficial to students and clinic staff. CONCLUSION: Providers were able to follow up on vulnerable patients more quickly, students were able to practice essential nursing skills during a time when safety concerns limited direct patient interaction, and patients continued to feel connected to health care providers during a global pandemic. [J Nurs Educ. 2022;61(4):205-207.].

The Association of COVID-19 on Organizational Attitudes in Primary Care Among Interprofessional Practice Clinics.

This article describes the association of COVID-19 on organizational attributes in primary care among 2 academic-practice partnership interprofessional collaborative practice (IPCP) clinics. Our team used a concurrent, triangulation repeated-measures study design to examine responses to the Survey of Organizational Attitudes of Primary Care (SOAP-C) instrument between January and December 2020. Analysis revealed statistically nonsignificant change over 12 months across all 4 subscales. Study results suggest that IPCP teams can function effectively through adversity. The IPCP model seemed to bolster resilience making it a viable model for ambulatory practices caring for vulnerable populations.

Interprofessional Collaborative Practice Model to Advance Population Health.

The purpose of this paper is to describe the development, implementation, and lessons learned associated with an interprofessional collaborative practice (IPCP) care delivery model initiated at the University of Alabama at Birmingham (UAB). The model emphasizes transitional care coordination in chronic disease management for underserved and vulnerable populations. The model operates within a clinic environment with care providers from a variety of disciplines who integrate individual case management and actualize leadership taken by the appropriate discipline based on the needs of each patient. Two clinics will be discussed - Providing Access to Healthcare (PATH) and Heart Failure Transitional Care Services for Adults (HRTSA) - both of which leverage the resources of an existing academic-practice partnership between the UAB School of Nursing and UAB Hospital (UABH) and Health System. Clinic target patient populations are uninsured adults with diabetes (PATH Clinic) and uninsured or underinsured adults with heart failure (HRTSA Clinic) who are discharged from UABH with no source for ongoing care. The model uses a nurse-led, team-based approach that involves multiple professions working together to provide care for high-need, high-cost patients. Clinics use 4 simultaneous bundles of care that include evidence-based treatment guidelines, transitional care coordination activities, patient activation strategies, and behavioral health integration. Engaged patients indicate very high levels of satisfaction with care and improved physical and mental health outcomes resulting in significant cost savings for the health system. Finally, IPCP team members report joy in their work within the clinics.

Evaluating interventions to delay the progression of prediabetes to type-2 diabetes mellitus in an uninsured Hispanic population.

BACKGROUND: Diabetes is a chronic progressive disease affecting 34 million Americans. The Centers for Disease Control and Prevention estimates that 12.5% of people aged 20 years or older diagnosed with diabetes are Hispanic. The American Diabetes Association further estimates that 84.1 million Americans aged 20 years and older have prediabetes based on fasting blood sugar and hemoglobin A1c (HbA1c) levels alone. LOCAL PROBLEM: In Georgia, the overall rate of diagnosed diabetes is 9.7%, undiagnosed is 6.5%, and prediabetes is 1.1%. The prevalence of diabetes for the Hispanic population in Georgia is 9% and is 10% among Clayton County residents. The purpose of this quality improvement project (QIP) was to evaluate interventions implemented to delay the progressions of prediabetes to type-2 diabetes in an uninsured Hispanic population. METHODS: Retrospective chart review was conducted comparing pre- and postmeasurements for HbA1c and body mass index (BMI) in Hispanic patients identified as having prediabetes. INTERVENTIONS: Patients with HbA1c of 5.7-6.1% were provided with a diabetes tool kit, whereas patients with an HbA1c of 6.2-6.4% were given the diabetes tool kit plus metformin. RESULTS: A decrease in mean HbA1c was noted in both groups of patients. However, a paired sample t-test indicated nonsignificant decrease in HbA1c for the diabetes tool kit group (p = .51) but significant decrease for the diabetes tool group kit plus metformin group (p < .01). CONCLUSIONS: Although this QIP did not reveal statistically significant changes in HbA1c and BMI for both groups, the results were clinically significant among this Hispanic population.

Sustainability of an Interprofessional Collaborative Practice Model for Population Health.

Sustainability is an important concept in implementation science, yet little about sustainability is published in leadership journals. Leaders are charged on a daily basis with initiating programs that make a difference; however, they are often not well prepared to design effective strategies to sustain their efforts. In a value-based health care industry where facilitating access to care, enhancing the patient experience, improving health outcomes, and reducing the cost of care are imperative, creating sustainability strategies that achieve these results is key. In this article, we describe the successful efforts within an academic-practice partnership to implement a sustainable interprofessional collaborative practice model emphasizing transitional care coordination in chronic disease management for advancing population health with underserved populations. A sustainability framework is presented along with lessons learned.

Low-cost thoracentesis simulation for nurse practitioner students.

The fast-paced hospital setting is not routinely a conducive environment for practicing procedural skills. Simulation learning can provide an opportunity for learners to achieve accuracy, confidence, and competence when performing the thoracentesis procedure. The cost associated with many commercial-brand manikins and the additional supplies needed to teach thoracentesis is expensive. However, thoracentesis is a skill many nurse practitioners (NPs) need to learn. The use of a whole, unstuffed turkey purchased at a supermarket to simulate a thoracentesis is a way in which NP students can safely practice this skill. Nurse practitioner students perform assessment skills on another student, whereas students perform the thoracentesis procedure on this turkey carcass. Nurse educators can teach NP students to safely, accurately, and efficiently perform a thoracentesis procedure using a low-cost simulator. Nurse educators can teach NP students how to perform a thoracentesis using a turkey carcass at a relatively low cost with a high yield.

Using Simulation and Competency Assessment to Decrease Inappropriate Referrals to a Comprehensive Vascular Access Team.

This department column highlights translation of research into health care quality practice. Achieving the highest quality of health care requires attention to creating and sustaining process efficiencies through the development of bedside provider competencies that result in workflow improvements and positive patient outcomes. An improvement intervention aimed at decreasing unnecessary referrals to a comprehensive vascular access team (CVAT) resulted in a 21% reduction in inappropriate consults to the team in approximately 6 weeks. The purpose of this article is to describe a simulation and competency assessment intervention aimed at increasing staff nurse proficiency in the emergency department for placing ultrasound-guided intravascular catheters, thereby reducing the number of inappropriate referrals to a CVAT team.

Kaizen: Interactive Gaming for Diabetes Patient Education.

Objective: An estimated 100 million Americans have diabetes, undiagnosed diabetes, a high risk of being diagnosed with diabetes, or prediabetes. Many complications can arise if diabetes is poorly managed. Hence, the need for adequate knowledge, skills, and ability to care for oneself, known as diabetes self-care management, is needed to reduce complication rates. We used an interactive platform that incorporates principles of gamification to enhance user engagement to enhance diabetes knowledge. The purpose of this descriptive pilot study was to discover what adult patients with diabetes thought about this novel educational approach to diabetes education. Materials and Methods: We collected focus group data from participants at a diabetes clinic after they played an interactive diabetes trivia game, on our software platform (Kaizen Education). Transcripts were coded and common themes were identified. Results: We conducted 9 focus groups that included 33 adult (age >18) participants who had diabetes. An overarching theme of play/gaming as a form of learning was apparent, and after analyzing the coding several themes emerged, including preferences and desired environments (clinic and home) for learning, desired players (including family, significant others), and a good balance of question difficulty. Conclusions: Participants were overwhelmingly positive about gamified education and felt empowered to lead discussions with their health care providers about diabetes self-care education, in a sense "flipping" the traditional clinic patient education paradigm. These results suggested that a flipped clinic approach could be beneficial, empowering, and engaging for patients.

Competency-based education in transitioning nurse practitioner students from education into practice.

Competency-based education (CBE) provides a framework for nursing programs including those educating nurse practitioners (NPs). The basic assumption of CBE is that the student will demonstrate acquisition of the identified essential knowledge, skills, and attitudes expected for the designated educational process before leaving the learning environment. The work done to date in developing competencies and progression indicators provides the critical basis to move toward a common language and clear expectations for the continuum of linear progression of proficiency. Entrustable professional activities (EPAs) are built on competencies and stated as measurable activities that providers can be expected to do, at varying levels of competence or trust or supervision, and allow the faculty member, preceptor, or supervisor to make decisions as to what teaching methods and level of supervision are needed. Numerous methods are used to measure competency in clinical skill knowledge, performance, and practice readiness including clinical preceptor feedback, objective structured clinical examination, and simulation, just to name a few. NP programs continue to struggle with the education practice gap between theory and the actual provision of care. The discussion about novel and reliable methods for measurement of competencies must address the strategic importance of a consensus about when, where, and how students can obtain the appropriate amount and type of experience and supervision required in the transition to independent practice. There is also a significant need for processes and standardized guidelines that can contribute to EPA development.

Evaluating Patient Navigation to Improve First Appointment No-show Rates in Uninsured Patients with Diabetes.

Free clinics increase access to care, however, patients frequently miss appointments. The purpose of this quality improvement project was to determine if providing patient navigation affects first appointment no-show rates and hemoglobin A1c (HbA1c) in uninsured patients with diabetes at a free clinic. For 6 months, all patients scheduled for new appointments received weekly patient navigation calls. First appointment no-show rates decreased by 17.7% (p = 0.01). Among patients who received at least one patient navigation call, a significantly greater proportion attended their first appointment (72%) compared to the show rate for those who did not receive a completed call (43%) (p = 0.004).

Improving Population Health Among Uninsured Patients with Diabetes.

Diabetes is a leading cause of morbidity and mortality; prevalence of diabetes is especially high in the southeastern United States among minority populations and those from lower socioeconomic sectors without access to health care services. The purpose of this project was to evaluate the clinical and financial outcomes of a nurse-led, interprofessional collaborative practice model that provides care coordination and transitional care for uninsured patients with diabetes. Data for this study were collected and evaluated from medical records of patients seen at the Providing Access to Health Care (PATH) Clinic between August 1, 2015, through May 30, 2017. Clinical outcomes were evaluated by comparing hemoglobin A1c (HbA1c) values before and after referral to the PATH Clinic. Cost savings to the academic medical center were evaluated by comparing costs associated with inpatient or emergency department encounters before and after referral to the PATH Clinic. A significant decrease in HbA1c (P < .0005) was noted for patients attending the PATH Clinic. In addition, financial analyses revealed a 55% decrease in pre to post PATH Clinic patients' direct costs. Similarly, a 42% decrease in the pre to post PATH Clinic patients' direct cost per encounter was noted. Average length of stay also was reduced when these patients were readmitted to the academic medical center. Results from this study support the effectiveness of the PATH Clinic model in caring for uninsured patients with clinically complex medical and social needs, often with behavioral health problems, who incur high health care spending and are often readmitted.

Using Data Analytics as Evidentiary Support for Financial Outcome Success in Nurse-Led Population-Based Clinics.

Achieving the highest quality in health care requires organizations to develop clinical improvements that result in measurable outcomes for success. The purpose of this article is to demonstrate an example of clinical quality improvement through the use of data analytics to generate evidence for financial return on investment in two nurse-led, population-based clinics.

A Community-Based Sensory Training Program Leads to Improved Experience at a Local Zoo for Children with Sensory Challenges.

Sensory processing difficulties are common among many special needs children, especially those with autism spectrum disorder (ASD). The sensory sensitivities often result in interference of daily functioning and can lead to social isolation for both the individual and family unit. A quality improvement (QI) project was undertaken within a local zoo to systematically implement a sensory training program targeted at helping special needs individuals with sensory challenges, including those with ASD, Down's syndrome, attention-deficit/hyperactivity disorder, and speech delay. We piloted the program over a 2-year period. The program consisted of staff training, provision of sensory bags and specific social stories, as well as creation of quiet zones. Two hundred family units were surveyed before and after implementation of the sensory training program. In this pilot QI study, families reported increased visitation to the zoo, improved interactions with staff members, and the overall quality of their experience. In conclusion, we are able to demonstrate that a sensory training program within the community zoo is feasible, impactful, and has the potential to decrease social isolation for special needs individuals and their families.

The Physiological Mechanisms of Diabetes and Aging on Brain Health and Cognition: Implications for Nursing Practice and Research.

A substantial proportion of individuals over the age of 65 years will experience some degree of cognitive impairment, and older adults with diabetes are at increased risk for these impairments. Such impairments can negatively affect activities of daily living and lead to a decrease in quality of life as well as increase caregiver burden. Cumulatively, the effects of diabetes and aging slowly diminish cognitive function, resulting in various degrees of cognitive impairment including dementia. In fact, older adults with diabetes have a 65% higher chance of developing Alzheimer disease than those without diabetes. This article reviews the synergistic effects of aging and diabetes on cognitive function. A discussion of the physiologic basis for these effects is included, in particular, the role of insulin in the brain. The final section of the article focuses on intervention strategies that can be used by nurses and allied healthcare providers to mitigate the influence of diabetes and aging so that optimal cognitive performance is maintained. Areas for future research are also discussed.

The synergistic effects of HIV, diabetes, and aging on cognition: implications for practice and research.

Thanks to highly active antiretroviral therapy, many people infected with HIV will likely live into old age. Although this is a welcome prognosis, new issues are emerging that may complicate the ability to successfully age in this clinical population. HIV and aging independently are related to cognitive impairments, so there are concerns that those aging with HIV may be more at risk of such cognitive impairments. Moreover, highly active antiretroviral therapy itself can create metabolic disorders, such as prediabetes and/or frank type 2 diabetes, which have also been linked to poorer cognitive functioning. Thus, concerns increase that, as people age with HIV and develop comorbid metabolic disorders that may lead to type 2 diabetes, they will be at triple risk of developing cognitive impairments that can impair everyday functioning and reduce quality of life. This article explores these issues and provides implications for practice and research.