Clinical Nurse Leader: Promoting Family Health

1
Clinical Nurse Leader Promoting Family Health

• Pamela N. Clarke and Carol Macnee
• Fay W. Whitney School of Nursing
• University of Wyoming

2
National Need for Clinical Leadership

• Health counseling has been evolving as cost
  efficient service Kaiser Healthsource
• Nursing is natural fit vs physicians, trained
  counselors or social workers
• Families need guidance negotiating the system and
  information (integration of care)
• AACNs CNL Movement community approach

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Clinical Nurse Leader in Community Health

• Masters prepared CHN
• Fit with model of care proposed in the state and
  AACN CNL
• AACN competencies critical to the model
• Generalist
• Educator
• Integration of care
• Advocate
• Population competencies
• Acute vs community focus

4
Unique Rural Environment

• Access and transportation issues in frontier
  state
• High-end specialty care out of state
• Negotiation of complex care systems across state
  lines
• Lack of care coordination is critical
• PHNs
• Working in under-funded health departments
• Inadequately prepared

5
New Service Model

• Public-Private partnership
• Builds on PharmAssist Program (direct service to
  individual re medication regimen)
• Timing of Wyoming project coincided with national
  Clinical Nurse Leader movement
• Need for data to support new model (business
  perspectiveefficient and effective)

6
Public-Private Partnership

• University of Wyoming College of Health Sciences
  (nursing and pharmacy)
• Human Capital Management Services (HCMS) manages
  all state health data (Medicaid, state health
  plan, uninsured)
• Data indicate families need help negotiating care
  system
• Need for family service model MS prepared nurse
  and pharmacist interprofessional team

7
HealthAssist Business Model

• Non-profit business developed with assistance
  from Business and Law Schools
• Long-term plan includes for profit venture
• Initial funding from the state 5 state agencies
  
• Pilot project targeted toward high users of
  medications services

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Family Success PilotChanging Delivery Systems
Program-centric
Family-centric
to
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Home Visit as the Core

• Conceptual shift patient-centered vs
  family-centered
• Home-based services key element
• Prevention and health promotion for all families
• Family empowerment
• Family advocacy and negotiation skills
• Development of family health plan
• Information and decision-making

10
Innovation Whats New?

• Funding!! Use of business model to sell the
  value of community health nursing
• Partnership with private business state
  agencies
• Advocacy Family negotiates with own providers
• Motivational Interviewing
• Highly skilled communication techniques to
  accomplish goals
• Potential for demonstration of cost effectiveness
• Especially w/ end of life care
• Care of people w/ chronic illness

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CNL Case Manager

• Family-focused (services directed toward family
  health and welfare)
• Empowerment (nurse teaches family advocacy
  skills)
• Family-driven (family members contact
  provider/physician)

• Home-based case management (medical model)
• Individual Patient Focus (case)
• Advocacy on behalf of patient
• Service Provider-driven(case manager contacts
  provider/physician)

12
Pilot Study through HCMS

• 200 Medicaid cases (using gt10 medications 2 or
  more state services) under age 65 in two counties
• Homogeneity on funding source
• Randomly assigned to intervention and comparison
  groups
• Consent with potential for delayed treatment

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Timeline for Project

• Acceptance of model (2003-2005) 2 years
• IRB Approval (5 state agencies) Fall, 2005
• Business plan (May, 2005) Ongoing communication
  within university system
• Board of Directors and EIN number (November,
  2005)
• Hiring staff Service separate (Fall, 2005)
• Staff training (difference between CNS and CNL
  family empowerment training for nurse and
  pharmacist) (December, 2005)

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Predicted Outcomes

• Evaluation Measures
• Pharmacy Outcomes Reduced rate of Adverse
  Drug Effects Improved family/caregiver
  knowledge of prescribed medications Reduced
  pharmacy cost Reduced number of drugs
• Medical Care Outcomes Less fragmentation of
  providers, reduced number of providers
  Reduced rate and cost of emergency room,
  technical, and institutional care
  Coordinated medical and pharmacy treatment among
  medical providers Case-finding family
  member needs

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Outcomes

• Evaluation Measures (Continued)
• CDC Health Related Quality of Life
• Summary index of unhealthy days
• Activities Limitation Module
• Healthy Days Symptoms Module
• Human Capital Development Achievement of
  family plan goals
• Cross Agency Coordination Discovery and
  recommendation for managing high cost families

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Preliminary Findings

• Referrals received to date 178 people
• Enrolled 93 participants
• Age break down
• lt 5yrs n18
• 3-14 n18
• 15-24 n16
• 25-34 n18
• 35-54 n12
• 55-64 n11
• Female n61 Male n32

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Preliminary Findings CDC Health Related Quality
of Life

• Forty-three percent describing health as fair to
  poor
• Nationally 14.2 report fair to poor health
  (2003)
• In Wyoming 12.3 report fair to poor health
  (2003)
• Thirty-six percent describe frequent mental
  distress
• In Wyoming 9.1 reported frequent mental distress
  (2003)
• Averaged 8.7 days w/ poor physical health
• Nationally the average is 3.4 days
• Averaged 9.9 days w/ poor mental health
• Nationally the average is 3.5 days
• Averaged 8.4 days where poor health limited usual
  activities
• Nationally the average is 2.0 days

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Implications

• This study of the CNL role is tackling some of
  the most needy clients in the state
• Pro Lots of room for improvement
• Con Very complex cases with great needs

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END

• Questions? Please email them to
  jstanley_at_aacn.nche.edu