Chronic Conditions and Care Transitions

• Among older adults, 85% have at least one chronic condition; 60% have at least 2 chronic conditions (National Institute on Aging, 2017).

• Parkinson’s disease (PD) is a chronic condition

• Those with chronic conditions register more physician visits, ER visits and hospitalizations with number increasing proportionally to number of chronic conditions. (Anderson, 2010; Berenson et al 2002)

Care Transitions

• Broadly defined, care transitions are “movement across and within settings of care and/or between providers (e.g. home to ER, home to hospital, hospital to SCF, rehabilitation center to home, etc)

• Care transitions are vulnerable times for older adults with chronic conditions

• Poor outcomes, fragmented care not uncommon

Nursing role in essential features of transitional care (Naylor et al, 2017)

Older adult and family

Engagement

Education

Managing complex care

Continuity of care

Well-being

Accountability

Objectives for Today

• Define transitional care concepts and elements as they pertain to Parkinson’s disease patients• Discuss key vulnerabilities of those with PD across care transitions

• Describe nursing research and education in transitional care stimulation for Parkinson’s disease

• Contemplate nursing care avenues to improve transitional care for those with PD

Today’s Presenters

Ø Diane M. Ellis, MSN, RN, CCRN (PI)Ø Shelley Hickey, MSN, RN (Co-I)Ø Melissa O’Connor, PhD, MBA, RN (Co-I)

BACKGROUND

ØTen million people worldwide suffer from Parkinson’s disease (PD)- estimated that nearly one million people will be living with PD in the U.S by 2020 which is greater than M.S, M.D and ALS combined (Parkinson's disease Foundation, 2018)

ØMissed or omitted medication occurs frequently in hospitalized patients with PD which increases length of stay (Martinez-Ramirez et al., 2015)

BACKGROUND

Ø Prior research indicates only 33% of hospitalized patients with PD in the US return home- 63% are discharged to some type of facility and 3.9% die (Mahajan et al., 2016)

Ø Missed, late, omitted or inappropriate medication can also cause significant comorbidity during hospitalization including falls, aspiration (DiBartolo, 2017)

Ø Hospitalized patients with PD do not receive their medications on time, experience an abrupt stoppage, and medications omitted or inappropriately prescribed(Parkinson’s Foundation, 2016)

BACKGROUND

Ø Patients who experience a transition in care are vulnerable for poor and costly outcomes (Anderson, 2010; Naylor, Aiken, Kurtzman, Olds & Hirschman, 2011)

Ø Sixty-one percent of PD patients who experience an interruption in medication timing or omissions suffer poor outcomes

Ø Leading to reduced ADLs along with loss of the ability to move, talk, swallow and participate in therapy

Ø Cost of inpatient care for PD patients has risen from $25,491 per hospitalization in 2002 to $40,802 in 2011 (Mahajan et al., 2016)

Initial Study Lost in Transition: Promoting Parkinson's Patient Medication Safety

The purpose of this study was to:Ø Increase awareness and educate undergraduate

faculty and nursing students regarding the importance of missed/omitted/delayed (MOD) PD medications during care transition

Ø Inclusion criteria – Senior nursing students and their clinical faculty in an Accelerated Bachelor’s degree program enrolled in Care of Adults and Older Adults with Complex Health Problems Course (Spring 2018 )

Second Study-An Intraprofessional Mock Code: Nurse Anesthesia and Baccalaureate Nursing Students- Parkinson’s Patient Missed/Omitted/Delayed Medication Unfolding Case Study Simulation

The purpose of this study was to:Ø Increase awareness and educate

undergraduate/graduate faculty and nursing students regarding the importance of missed/omitted/delayed (MOD) PD medications during care transition and promote intraprofessional comfortability

Ø Inclusion criteria – Senior nursing students and their clinical faculty in a Bachelor’s degree program enrolled in Care of Adults and Older Adults with Complex Health Problems Course and Graduate Senior MSN Nurse Aesthesia Students (Fall 2018 study)

DESIGN- BOTH VU IRB APPROVAL STUDIES

Conducted in five steps: Ø 1) Informed consent Ø 2) Pre-test Ø 3) Simulated unfolding case study Ø 4) Debriefing sessionØ 5) Post-test

GAPS IN KNOWLEDGE

Nursing School Faculty Results:Ø Seventy percent of nursing faculty responsible for PD

content did not feel comfortable or confident in their knowledge of the material; 33% of those surveyed had no PD content in their curricula; and 46% had no clinical mentored experience with patients suffering from PD (Vernon, Bunting-Perry, & Dunlop, 2012)

Ø PD experts reviewed the readings and lecture materials supplied by the participating schools and found that more than 97% of the materials submitted were out of date, misleading, or irrelevant (Vernon, Bunting-Perry, & Dunlop, 2012)

AIMS

The purpose of these studies were to:Ø Increase awareness and educate

undergraduate/graduate faculty and nursing students regarding the importance of missed or omitted PD medications during care transitions

Ø Inclusion criteria – Senior nursing students and their clinical faculty in an accelerated Bachelor’s degree program enrolled in Care of Adults and Older Adults with Complex Health Problems Course and senior MSN nursing education students

METHODS- BOTH STUDIES

Ø No grade associated with the pre- or post-testØ Participation voluntary

Ø lack of participation not reflected in the students’ grade

Ø Participants assigned a number an identifier when completing the pre- and post-test

INITIAL STUDY RESULTS (STUDENTS N=94)Aim = increase knowledge about PD medication safetyGoal = retention of knowledge to promote safety

Ø 53.6% increase in student’s knowledge importance of PD medication timing

Ø 54.3 % increase in student knowledge best practices to prevent missed or omitted PD medications

Ø 71.3 % increase in student knowledge side effects and complications of missed or omitted PD medications

Ø 46.8% increase in student knowledge priority nursing care practices for patients with PD

INITIAL STUDY RESULTS (Faculty N=7)Aim = increase knowledge about PD medication safetyGoal = retention of knowledge to promote safety

Ø 71.4% increase in faculty knowledge importance of PD medication timing

Ø 57.1% increase in faculty knowledge best practices to prevent missed or omitted PD medications

Ø 85.7% increase in faculty knowledge side effects and complications of missed or omitted PD medications

Ø 57.0% increase in faculty knowledge priority nursing care practices for patients with PD

Second Study: AIM= increase PD medication safety/knowledge GOALS= retention knowledge/ promote safety/ increase intraprofessionally comfortability

RESULTS- Students (N=94 UG) (N=24 SRNA) Quasi-experimental design- following the intraprofessional mock code simulation

Ø BSN UG increased knowledge -Carbidopa/Levodopa administration route (percent increase 27.7%)

Ø SRNA showed no change in knowledge (0%)Ø BSN UG (percent increase 74%) Ø SRNA (percent increase 27.8%) -knowledge

related acceptable to miss/omit/delay PD medication administration.

RESULTS- (Faculty/Students)

Ø Clinical faculty (N=4) demonstrated no change in knowledge

Ø 57.4% undergraduate students reported minimal to no comfort level in working with anesthesia personnel pre-simulation

Ø Post-simulation 94% of the students who reported minimal to no comfort indicated a response of moderate to extreme comfort

BENEFITS OF:

Problem-Based Learning (PBL)Ø PBL is more effective for long-term knowledge retention,

performance or skill-based assessment and mixed knowledge and skills (Strobel & van Barneveld, 2009)

Reflective PracticeØ Reflection has the opportunity to enhance clinical

reasoning while having a positive impact on patient care (Oluwatoyin, 2015)

Case Based Learning (CBL)Ø Learning that goes beyond simple identification of correct

answers and is more aligned with either evidence of critical thinking or changes in behavior and generalizability of learning to new cases. (McLean, 2016)

Unfolding Case Study Simulation – utilizing PBL, CBL and Reflective Practice

Ø Integrate knowledgeØ Promote higher level thinkingØ Instill best practiceØ Present clinical situations not encountered in

practice but are “need to know” situationsØ Link theory to practiceØ Allow some preparation prior to simulationØ Instructor guided reflection during debriefing

PATIENT SAFETY IMPLICATIONS

Ø Three out of 4 people with Parkinson’s disease do not get their medication on time in the hospital

Ø People with Parkinson’s are hospitalized 50% more than their peers without the condition

Ø People with Parkinson’s suffer avoidable complications at a higher rate than people without Parkinson’s, resulting in longer hospital stays and a higher risk of mortality

Retrieved from: http://parkinson.org/sites/default/files/Parkinson%20Report%20-%20Spring%202012_0.pdf

CALL TO ACTION

Ø Integrate simulation as yearly a competency in health care settings

Ø Encourage institutions of nursing education to implement teaching strategies that permit retention of knowledge about timing of PD medications

Ø Partner with transitional care teams to integrate processes that prevent missed or omitted PD medications

CARE TRANSITIONS

• “Transitions, or ‘handoffs,’ are vulnerable exchange points that contribute to unnecessarily high rates of health services use and health care spending, and they expose chronically ill people

to lapses in quality and safety.” (Naylor et al., 2011)

IDENTIFYING TRANSITIONAL CARE NEEDS

• While many chronically ill older adults experiencing a care transition are vulnerable for poor outcomes, PD patients are at particularly high risk especially when admitted

• Non-adherence to at-home schedules and delays in obtaining medication can cause re-emergence of severe disease symptoms and dopamine withdrawal syndrome

• Goal is to “promote the safe and timely transfer of patients from one level of care to another or from one type of setting to another” (Naylor et al., 2011)

IDENTIFYING TRANSITIONAL CARE NEEDS

• Health care providers – particularly nurses, can help mitigate risk among hospitalized patients with PD

• Most often it is the patients and their caregivers who are best informed about their needs

• Critical that inpatient nurses listen carefully, investigate home routines, conduct a thorough medication reconciliation, and encourage patient and/or family involvement while understanding that PD medication routines are unique in this population and individually titrated

FUTURE PROJECT

Ø An Interprofessional Mock Code-Parkinson’s Missed/Omitted/Delayed (MOD) Medication Simulation- Philadelphia College of Osteopathic Medicine (PCOM)

Ø Medical Students (Fourth Year)Ø Doctorate of Psychology Students Ø Senior Nursing Students Ø Senior Nurse Anesthesia Students

References

• Anderson, G. (2010). Chronic Care: Making the case for ongoing care: Robert Wood Johnson Foundation. http://www.rwj.org/pr/product.jsp?id=50968.

• Berenson, R., Horvat, J. (2002). The clinical characteristics of Medicare beneficiaries and implications for Medicare reform. Washington, DC: The Center for Medicare Advocacy conference on Medicare coordinated care.

• Centers for Disease Control and Prevention (2016). Well being concepts. Retrieved March 25, 2018, http:www.cdc.gov/hrqol/wellbeing.htm#three.

• DiBartolo, M. (2017). Enhancing care for hospitalized patients with Parkinson’s Disease: Development of a formal educational program for nursing staff. Journal of Gerontological Nursing, 43(5), 18-22. doi:10.3928/00989134-20170223-02

• Mahajan, A., Balakrishnan, P., Patel, A., Konstantinidis, I., Nistal, D., Annapureddy, N., Sidiropoulos, C. (2016). Epidemiology of inpatient stay in Parkinson’s disease in the United States: Insights from the Nationwide Inpatient Sample. Journal of Clinical Neuroscience, 31, 162-165. doi:10.1016/j.jocn.2016.03.005

References

• Martinez-Ramirez, D., Giugni, J. C., Little, C. S., Chapman, J. P., Ahmed, B., Monari, E., Okun, M. S. (2015). Missing dosages and neuroleptic usage may prolong length of stay in hospitalized Parkinson’s Disease patients. PLoS ONE, 10(4), e0124356. doi:10.1371/journal.pone.0124356.

• McLean, S. (2016). Case-based learning and its application in medical and health-care fields: A review of worldwide literature. Journal of Medical Education and Curricular Development, 3, 39-49. doi:10.4137/JMECD.S20377.

• National Institute on Aging (2017). Supporting older patients with chronic conditions. Retrieved April 7, 2019 www.nia.nih.gov.

• Naylor, M. D., Aiken, L. H., Kurtzman, E. T., Olds, D. M., & Hirschman, K. B. (2011). The importance of transitional care in achieving health reform. Health Affairs, 30(4). doi:10.1377/hlthaff.2011.0041

References

• Naylor, M.D., Shaid, E.C., Carpenter, D., Gass, B., Levine, C., Li, J.,…Williams, M.V. (2017). Components of comprehensive and effective

transitional care. Journal of the American Geriatrics Society, 65(6), 1119-1125.

• Oluwatoyin, F. E., (2015). Reflective practice: Implications for nurses. IOSR

Journal of Nursing and Health Science, 4(4), 28-33. doi: 10.9790/1959-0443283.

• Parkinson's Foundation. (2012, 2016, 2018). Retrieved from https://parkinson.org/

• Strobel, J., & Van Barneveld, A. (2009). When is PBL More Effective? A meta-synthesis of meta-analyses comparing PBL to conventional classrooms. Interdisciplinary Journal of Problem-Based Learning,3(1).

doi:10.7771/1541-5015.1046

• Vernon, G. M., Bunting-Perry, L., & Dunlop, R. (2012). Edmond J. Safra Visiting Nurse Faculty Program: An innovative strategy to advance Parkinson's disease patient care [Abstract]. Movement Disorders, 27(Suppl

1), 942.

Nursing Educational Programs

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