Evidenced-based Practice for the Nurse Care Manager

1. Evidenced-based Practice for the Nurse Care Manager Telana Fairchild, Erica Magaziner,ZofiaStec, Ashley Rosati Nurse Practitioner Students UMass - Worcester, Graduate School of Nursing N/NG 603B

2. Care Managers EBP for NCM • Provide direct patient care by: • Coordinating care • Helping patients navigate the system • Improving access for patients • Communicating across the care team • Deliver patient-centered care

3. Direct role in patient care EBP for NCM Provide patient education and training in self-management skills Coordinate care with specialists/clinicians Connect patients with community resources and social services.

4. Care manager vs. Casemanager 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 • Help practices organize& prioritize quality improvement (QI) activities • Train staff to understand & use QI data effectively • Promote effective communication among practice staff EBP for NCM

5. Care Managers: Evidenced-Based PracticeNurse Care Manager Contribution to Quality of Care EBP for NCM 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

6. Care Managers: Evidenced-Based PracticeNurse Care Manager Contribution to Quality of Care EBP for NCM 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.

7. Care Managers: Evidenced-Based Practice EBP for NCM 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 Zealand Design/Participants: RCT with a sample of 351 individuals assessed as being at risk for permanent residential care placement Interventions: Care management program consisting of a professional care managers aligned with a family physician Measurements: Rates of permanent residential care placement and mortality Results: 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.

8. Care Managers: Evidenced-Based Practice Barriers and facilitators of treatment for depression in a Latino community 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. 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) EBP for NCM

9. Care Managers: Evidenced-Based Practice EBP for NCM 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 populations Design & 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 & costs Results: PHQ-9 scored declined 7.9 points (P<0.001). Costs estimated $512 per participant Conclusions: adding a depression care manager to an existing diabetes management team was effective at reducing depressive symptoms at a reasonable cost

10. Teach-Back Method 10 EBP for NCM

11. Addressing the Problem EBP for NCM • 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.

12. Health Literacy EBP for NCM ….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

13. Teach-Back Method EBP for NCM • 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.

14. Teach-Back Method EBP for NCM • 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.

15. Why Use Teach-Back? EBP for NCM • 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.

16. Why Use Teach-Back? EBP for NCM • Prevents chronic illness symptoms from worsening • Prevents re-admissions • Prevents patient medication errors • Improves compliance with preventative care; immunizations, screenings, appointments • Improves healthcare costs

17. Common Topics for Teach-Back EBP for NCM • Insulin injections • Use of Inhaler • Medication changes • Diet changes • Tracking daily weights • Chronic disease self care

18. How to use Teach-Back EBP for NCM “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?”

19. How to use Teach-Back EBP for NCM Key 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

20. Motivational Interviewing EBP for NCM 20

21. 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 21 EBP for NCM

22. 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 22 EBP for NCM

23. 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 23 EBP for NCM

24. 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 24 EBP for NCM

25. 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. 25 EBP for NCM

26. Four Skills of MI • Reflective listening • Asking open-ended questions • Affirming • Summarizing 26 EBP for NCM

27. 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 27 EBP for NCM

28. 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?” 28 EBP for NCM

29. 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.” 29 EBP for NCM

30. 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?” 30 EBP for NCM

31. 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” 31 EBP for NCM

32. 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 32 EBP for NCM

33. 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…” 33 EBP for NCM

34. 34 EBP for NCM

35. Chronic Disease Management 35 EBP for NCM

36. 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. 36 EBP for NCM

37. 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 37 EBP for NCM

38. Asthma Management and Education • Delivery of Information • Utilize interactive and non-interactive methods of information delivery • Interactive 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. 38 EBP for NCM

39. Asthma Management and Education • 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). 39 EBP for NCM

40. Asthma Management and Education • 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. 40 EBP for NCM

41. 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. 41 EBP for NCM

42. Diabetes Management and Education • Assess for compliance at each visit • Maintaining a daily FBS log? • Taking medications correctly? • Following an low sugar ADA diet? 42 EBP for NCM

43. Diabetes Management and Education • 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 assessments 43 EBP for NCM

44. Safety! Medication Falls 44 EBP for NCM

45. 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 Safety http://www.health.gov/paguidelines/guidelines/default.aspx EBP for NCM

46. Evidence Based Intervention: Fall Prevention Safety in the home: About 50% of falls Use checklist Clutter in walkways In-reach Grab-bars Non-slip mats Lighting Alert System EBP for NCM

47. Evidence Based Intervention: Fall Prevention Medication: Review Educate Advocate Use of Vitamin D Vision: Advocate Optometrist Compliance EBP for NCM

48. 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 48 EBP for NCM

49. 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#a3 Britt, 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)00141-1 Caro, 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 Dulceand IMPACT. Diabetes Care, 31, p. 1324-1326. EBP for NCM

50. References: EBP for NCM 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.aspx Kessels, 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, 50-58 Motivational 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