Family Caregivers Employed by Home Care Agencies: Lessons Learned From Switzerland and the United States.

Background: Increasing demands for home care staff has been triggered in the past decades by shorter hospital length of stay, and a shift of responsibility for complex care regimens to private households. Therefore, an innovative model to employ family caregivers in home care agencies is expanding in Switzerland and the United States. This policy brief aims to identify core characteristics of the model and analyze its potential benefits and challenges. Evidence: The model is expanding based on legal ground but without the requisite scientific evidence. After an initial patient assessment by a registered nurse, and assigned hands-on tasks to family caregivers, the salary is derived from payer reimbursement. Policy Options and Recommendations: Standards need to be in place to determine the family caregivers qualification that are specific to the client situation of all age groups. Supervision of quality of care, labor law, and blurred roles of biographical relationships remains at the responsibility of the home care agency. Conclusion: Further research for the data-driven exploration of the model is needed to inform the many stakeholders involved.

Telehealth Policy and the Advanced Practice Nurse.

Telehealth is an efficient and effective method of care delivery used by advance practice registered nurses (APRNs) nationally, especially in the wake of the coronavirus disease 2019 pandemic. With the ever-changing rules and regulations governing telehealth practice, the APRN may struggle to keep abreast. Telehealth is governed by legislation and regulation in addition to telehealth-specific laws. APRNs delivering care through telehealth must be informed about the crucial aspects of telehealth policy and how their practice is affected. Telehealth-related policy is complex and evolving and varies by state. This article provides APRNs with essential knowledge about telehealth-related policy to support legal and regulatory compliance.

Utilizing a Standardized Handoff Initiative Incorporating Both Medical Clearance Postoperative Recommendations and Orthopaedic-Specific Context to Improve Information Transfer.

Patients undergoing total joint arthroplasty (TJA) with multiple comorbidities require medical clearance recommendations from their primary care provider, which if not adhered to can lead to adverse postoperative complications. In this quality improvement initiative, we explore the impact of a standardized handoff process incorporating medical clearance postoperative recommendations and orthopaedic-specific context on information transfer in TJA. A systematic review of quantitative and qualitative studies from 2014 to 2019 was completed to draw a conclusion about the best practice methods for the development of a standardized handoff process. Prior to implementation, evidence was reviewed to inform activities such as baseline chart audits, attainment of stakeholder input regarding handoff, exploration of wound closure equipment utilization, and standardization of a structured "smart phase" that incorporates medical clearance recommendations and orthopaedic-specific context information. After provider education was completed and the new handoff approach initiated, data were collected to compare postintervention outcomes such as transfer of information and wound kit distribution cost analysis. At baseline, 42% of patients had medical clearance postoperative recommendations handed off when they were provided. At completion, the new handoff smart phrase was used 97% for the first handoff and 100% for the second handoff. Medical clearance postoperative recommendations were captured in the electronic health record 83% of the time when they were provided. When the new smart phrases were utilized, wound closure, precautions, and postoperative void status were always handed off. Once wound closure technique was specified, bedside nurses were able to provide the appropriate wound closure removal equipment at discharge, projecting cost savings of $0.69 per case (∼234 cases per month). The use of a standardized handoff smart phrase that includes specialty specific context and postoperative medical management requirements successfully improved the information transfer between providers in a large academic orthopaedic medical center.

Using Lean Six Sigma to Increase the Effectiveness of an Evidence-Based Quality Improvement Program.

BACKGROUND: Evidence-based quality improvement (EBQI) is an established methodology for identifying nursing practice changes that improve health care quality and safety. However, EBQI itself does not provide a framework for navigating the barriers to practice change. LOCAL PROBLEM: An EBQI program in an orthopedic specialty hospital fostered many successful quality improvement projects. However, program participants frequently encountered barriers to project implementation. METHODS: Lean Six Sigma (LSS) principles, tools, and strategies were incorporated into the EBQI program to help participants overcome organizational barriers to successful implementation. INTERVENTIONS: LSS interventions included stakeholder alignment, process analysis, change management, project management, structured check-ins, mentoring, and organizational recognition. RESULTS: The addition of LSS principles gave EBQI project leaders new tools for gaining executive support, securing resources, and overcoming organizational inertia to facilitate effective practice change. CONCLUSIONS: Lean Six Sigma can increase the effectiveness of an EBQI program.

Design and outcomes of a nurse practitioner preceptor development program.

ABSTRACT: Nurse practitioners (NPs) are educated to provide high-quality patient- and family-centered care to underserved, culturally diverse, medically complex populations. Nurse practitioner faculty plan curricular activities that challenge NP students to critically assess individuals and populations with the goal of preparing NP students to be "practice-ready" upon graduation. Nurse practitioner clinical training occurs in practice settings with NP preceptors, with specific areas of clinical expertise. However, there is a lack of NP clinical preceptors educationally prepared to clinically teach and evaluate NP students. This article presents the design, implementation, evaluation, and outcomes from a 3-year grant funded by the United States Human Resources and Administration Services that featured a web-based Primary Care Nurse Practitioner Preceptor Development Program. Ninety percent of NPs who precepted NP students completed all web-based learning modules. Preceptors with educational preparation via online modules to guide NP student learning in clinical settings are a critical resource for faculty to prepare NP students to be practice-ready upon graduation. This web-based learning platform for online NP preceptor education may be a successful approach for expanding and improving the NP preceptor pool nationwide.

Tactics for Teaching Evidence-Based Practice: Enhancing Active Learning Strategies With a Large Class of Graduate EBP Research in Nursing Students.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

The Influence of Clinical Decision Support on Diagnostic Accuracy in Nurse Practitioners.

BACKGROUND: Clinical decision support systems (CDSSs) at the point of care are evidence-based interventions that have demonstrated incremental positive impact on quality of healthcare delivery over the past two decades. Existing best practices inform strategies to promote adoption and achievement of targeted outcomes. The purpose of this improvement project was to conduct a pilot implementation to understand the contextual factors and readiness for dissemination of a newly acquired electronic CDSS by evaluating its influence on diagnostic accuracy in nurse practitioners (NPs) functioning in a community health setting. AIMS: The specific aims of this project were to measure and compare diagnostic accuracy in a pilot group before and after CDSS use, educate clinicians about the system and pilot its use, and then leverage the experience to design the practice-wide CDSS dissemination strategy. METHODS: The project engaged a subset of NPs from a home-based primary care practice and other organizational stakeholders who provided tangible support and necessary resources for successful adoption of this innovation in practice. A structured conceptual model of Evidence-Based Practice Improvement enhanced with elements of the Promoting Action on Research Implementation in Health Sciences framework was used to guide the development, implementation and evaluation of this practice improvement initiative. A group of seven NP representatives of the practice participated in the project. Data collection was composed of small tests of change (plan-do-study-act) cycles at the local practice level, measuring achievement of improvement of the chosen outcome of correctness of medical diagnosis evidenced by appropriate substantiating clinical documentation. LINKING EVIDENCE TO ACTION: In this home visiting primary care practice setting, use of a CDSS by NPs achieved eventual improvement in diagnostic accuracy and clinical documentation, as demonstrated on chart audit, though the improvement was not sustained over time. The pilot findings ultimately informed decision making about CDSS dissemination strategies and future uses of the system. When appropriately deployed, a CDSS offers the potential to improve professional practice, support differential diagnosis and evidence-based treatment, and provide detailed information about the disease state to facilitate robust clinical documentation.

Fostering evidence-based practice to improve nurse and cost outcomes in a community health setting: a pilot test of the advancing research and clinical practice through close collaboration model.

Although evidence-based practice (EBP) improves health care quality, decreases costs, and empowers nurses, there is a paucity of intervention studies designed to test models of how to enhance nurses' use of EBP. Therefore, the specific aim of this study was to determine the preliminary effects of implementing the Advancing Research and Clinical practice through close Collaboration (ARCC) model on nurses' EBP beliefs, EBP implementation behaviors, group cohesion, productivity, job satisfaction, and attrition/turnover rates. A 2-group randomized controlled pilot trial was used with 46 nurses from the Visiting Nurse Service of New York. The ARCC group versus an attention control group had stronger EBP beliefs, higher EBP implementation behaviors, more group cohesion, and less attrition/turnover. Implementation of the ARCC model in health care systems may be a promising strategy for enhancing EBP and improving nurse and cost outcomes.

Building bridges in academic nursing and health care practice settings.

The purpose of this article is to describe the development and implementation of a shared position with a focus on evidence-based practice (EBP) between the Visiting Nurse Service of New York and the Lienhard School of Nursing, Pace University. A preexisting relationship between the two institutions in providing student experiences in a community setting paved the way for the evolution a new collaborative effort. The shared position was initially conceived by two of the authors as an outcome of research they were conducting in the home care setting, which tested a model of mentoring frontline nurses in the EBP process on health care professional and patient outcomes. An initial conception of the new role provided a working document for discussions between the two institutions and the creation of a workable contract. The implementation of several initiatives has already provided support for the position, and each partner has benefited from building this bridge between nursing education and service. Benefits include advancing knowledge of and implementing EBP in both settings and promoting collaborative, clinically related scholarship.

A model for home care clinician and home health aide collaboration: diabetes care by nurse case managers and community health workers.

Researchers at Johns Hopkins University conducted a randomized clinical trial to test the effect of nurse case management and community health worker interventions on diabetes control among inner city African Americans. The results demonstrated that the greatest improvement occurred when nurse case managers and community health workers worked together. This study has implications for how nurse/home health aide collaboration can enhance diabetes management in home care.