The number of advanced practice registered nurse students and graduates increased under the Centers for Medicare & Medicaid Services’ Graduate Nurse Education demonstration project, according to a new report to Congress by the Department of Health and Human Services. “The GNE demonstration had a positive impact on APRN growth, and helped transform clinical education within participating GNE schools of nursing,” the evaluation report concludes.
The Affordable Care Act authorized the Medicare demonstration to test whether paying eligible hospitals to help offset the costs of clinical training for APRN students could help increase the nation’s primary care workforce. In 2012, CMS selected five hospitals affiliated with 19 university schools of nursing (including the University of Arizona College of Nursing) and hundreds of community clinical partners and collaborating health systems to participate in the program: Duke University Hospital in Durham, NC; Hospital of the University of Pennsylvania in Philadelphia; Memorial Hermann-Texas Medical Center in Houston; Rush University Medical Center in Chicago; and HonorHealth Scottsdale (AZ) Osborn Medical Center. The AHA’s American Organization of Nurse Executives subsidiary played a significant role in developing the original concept for the demonstration.
CHAP Leadership Team Audrey Russell-Kibble, DNP, FNP-C, FAANP, CHA Project Coordinator at the College (author), Theresa Allison, DNP, FNP-C, CHAP Assistant Project Coordinator, and Allen Prettyman, PhD, FNP-BC, FAANP, Director of Practice Innovations
Background & History
The CHAP was the inaugural nurse practitioner (NP) faculty practice opportunity at the College of Nursing. The notion of a college providing practice opportunities for NP faculty was novel in 2012. To promote the vision and innovation of faculty NP practice, Dean Joan Shaver, PhD, FAAN outlined strategic plans to support unique faculty NP practice opportunities. Five years ago, during a lively discussion with Thomas Ball, MD, Medical Director of the University of Arizona Health Plans (UAHP) the vision of faculty NP practice at the UA CON became a reality.
CHAP Staffing Structure
The CON developed an agreement with the UAHP to perform Comprehensive Health Risk Assessments for their Medicare Advantage Plan members. The CON nurse practitioner faculty are given workload credit and are assigned to the CHAP to accomplish the comprehensive health risk assessments in the community using a home health care delivery model. Because the assessments are scheduled in the home they allow scheduling flexibility for the faculty allowing faculty members to work in the program part-time to accommodate faculty/teaching responsibilities. The part-time hours benefit the faculty by providing clinical practice hours required for APRN licensure. Most importantly the NP faculty mentor NP students and support Doctor of Nursing Practice (DNP) student projects.
CHAP Scheduling Efficiency
CHAP visits are scheduled for one hour with an additional hour allotted for completing the extensive documentation. The visits are clustered within a zip code to provide efficiency as the NPs travel from home to home.
Language translation services are provided by the UAHP through phone translation. If the faculty NP is fluent in the language of the member, they are matched for a visit. Various faculty NPs have demonstrated fluency in Spanish, German, and Russian languages. ASL translation services are also available with an ASL translator assigned to accompany the faculty NP to the home.
The CHA Documentation
The Office of Learning and Innovation Technology Innovations (LHTI) at the CON and CHAP developed an electronic documentation system to capture the elements of the member appointment. The data gathered to complete the CHA is entered into an electronic secured SQL database. The raw data is easily de-identified, stored, and is available for research activities.
CHA Data Elements
• Demographic data
• Health history
• Surgical history
• Listing of the member’s specialists
• Documentation of the member’s completion of advance health care directives
• Medications review
• Recent Emergency Department (ED) and hospital admission history
• Comprehensive social history
• Family history
• Screening Tools include the PHQ-4 to assess for depression and anxiety, the Timed Up and Go test that is a falls risk assessment, the CDC-HRQOL-4 Modified to assess quality of life, a Modified PAR to review physical activity, a MINI-COG to evaluate for changes in memory.
• Physical assessment data that includes a complete neurological examination
• Functional assessment of activities of daily living (ADL) and instrumental activities of daily living (IADL)
• Adaptive equipment used and needed
• Health maintenance: Screenings, tests, immunization review
• Chronic conditions: Screenings, tests, exams, medication review
• Case management referral options are reviewed
An Assessment is provided that outlines all diagnoses, problems, symptoms, and potential problems, for example: a high risk for falls. The assessment describes the current status of each problem, current meds used to treat the problem, and identification of further testing or assessment needed. Plans are formulated and specific follow-up is suggested.
A detailed Plan and Recommendations for the Primary Care Provider (PCP) are outlined and a copy of the entire CHA is sent to the PCP.
The Members
The health plan members are dual eligible for Medicare/Medicaid. This year the members range in age from 21 to 97 years. The majority (63%) are over 65 years of age and over half are female (57%).
Potential Savings to the Health Plan/Medicare
The nurse practitioners repeatedly refer members to case management in the health plan for assistance with care. Some examples of specific case management referrals are for members at risk of falls, members who need urgent home health care assistance, members who have severe depression. Within the home the NPs have helped members with the use of a Holter monitor, how to use DME, how to make their homes safe.
Members are educated on services available to them such as eye exams with optometry, dental services, transportation to care, and over the counter (OTC) medications.
There is no doubt that there are innumerable times that ED and hospital readmissions are averted by the timely accomplishment of the risk assessments by our faculty NPs.
Summary
The CHAP is providing excellence in assessment, caring, and collaboration with the UAHP to provide assessments that benefit: (a) the Medicare Advantage Plan members by way of a comprehensive health assessment visit at their home with knowledgeable faculty NPs, (b) the faculty NPs who have specific dedicated practice hours to fulfill the obligation of clinical practice hours for continued certification, (c) DNP students who are given the opportunity to have faculty NPs work with them one-on-one to tune up their assessment skills, as well as, increase their knowledge of complex care management of chronic disease, and (d) the UAHP by way of fulfilling their obligation to offer the risk assessment to their dual eligible members on an annual basis.
The UAHP is very pleased to have this collaborative care relationship within the University community. The CHAP and faculty NPs are given kudos by the UAHP leadership, case management, and members in the Medicare Advantage plan, for a job well done.
National Hartfold Center of Gerontological Nursing Excellence
National Hartfold Center of Gerontological Nursing Excellence
TUCSON, Ariz. – Two faculty members at the University of Arizona College of Nursing were selected for fellowship in the prestigious American Academy of Nursing (AAN), one of the highest honors in the nursing profession.
Dr. Jane Carrington, PhD, RN, associate professor and Kate Sheppard, PhD, RN, FNP, PMHNP-BC, FAANP, clinical associate professor, join the existing group of 16 AAN fellows at the UA College of Nursing.
Drs. Carrington and Sheppard join 173 national and international nurse leaders who were inducted as fellows Oct. 7 during the Academy’s annual meeting and conference in Washington, D.C. Chosen by top leaders in the field, selection criteria include evidence of significant contributions to nursing and health care and influence on health policies and the health and wellbeing of all.
Dr. Carrington is a 2008 graduate of the UA College of Nursing PhD program and she was inducted as a fellow of the Western Academy of Nurses in 2016. A nationally recognized expert in nursing informatics and health-care technology, Dr. Carrington is conducting a three-year study funded by the National Institutes of Health, National Institutes of Biomedical Imaging and Bioengineering, to increase patient safety by enhancing nurse-to-nurse communication. By sophisticated augmenting of the electronic health record, clinical data is analyzed and used to trigger alerts that herald an imminent or emerging serious clinical event linked to a higher risk of unexpected patient death. She and her team aim to improve nurses’ identification and reporting of clinical events to prevent adverse consequences and save lives.
As an educator, Dr. Carrington is known for her innovative teaching methods that include using Twitter assignments to engage her students and using game theory as the foundation for several of her online courses. A highly sought-after mentor, during the Western Institute of Nursing conference, Dr. Carrington has led symposiums with her PhD and DNP students that showcases their work focused on innovations to engage nurses, providers and patients in effective communication.
Dr. Sheppard has made significant, sustained contributions to the field by transforming nursing and Advanced Practice Registered Nurse (APRN) education programs, vastly improving rural emergency health-care access, and applying interventions directly into clinical practice. Furthering emergency health in rural Northeast California, she worked as a mobile intensive care nurse (MICN), family nurse practitioner and educator; developed regional educational programs for fire departments, pre-hospital providers and nurses; and taught all their didactic and clinical courses, including courses for first responders, paramedics and MICNs. She procured grants to purchase advanced life support equipment, including on ambulances. Her efforts moved patient care from basic stabilization to highly skilled care delivered by paramedics and MICNs.
Dr. Sheppard’s awards include Regional MICN of the Year, induction as a fellow of the American Association of Nurses Practitioners in 2011, and the Western Academy of Nurses in 2014. She is a multiple recipient of the Excellence in Graduate Teaching Award from the UA College of Nursing (2012 and 2014). As a psychiatric mental health nurse practitioner, Dr. Sheppard focuses her research on compassion fatigue among nurses, which according to available literature, affects 30 to 90 percent of nurses, depending on the specialty in which they practice. Compassion fatigue is evident when being a health-care provider creates more sadness, stress or exhaustion than satisfaction, and providers begin to forego their own self-care.
Through the support of an American Nurse Practitioner Foundation research grant and the UA College of Nursing Laurence B. Emmons Research Award, Dr. Sheppard has developed a program of compassion fatigue awareness and training, which has been integrated into the college’s Doctor of Nursing Practice (DNP) curriculum. In the program, clinicians learn about three key concepts: burnout, secondary traumatic stress and compassion satisfaction, and practice strategies for heightened self-awareness of physical and mental discomfort and reflection on key triggers. She has consulted for more than 25 state, national and international organizations intent on reducing compassion fatigue.
The American Academy of Nursing is comprised of more than 2,200 nurse leaders in education, management, practice, policy and research. With the addition of this newest class, the Academy fellows represent all 50 states, the District of Columbia and 24 countries.
Nursing Informatics Help Nurses Make the Best Decisions for Patient Outcomes
University of Arizona College of Nursing Associate Professor Dr. Sheila Gephart had an epiphany when she realized that unwieldy electronic health systems were impeding the quality of work for nurses on the job. In the midst of creating an international quality registry for babies born with low birthweight, she discovered that a large amount of patient data was slipping unused through the cracks. If the point of electronic health records is to provide quality outcomes for patients, she concluded, then there was clearly room for improvement to support clinical decision-making, especially for nurses.
Last year, Dr. Gephart and her co-author, Dr. Karen Dunn Lopez, published a paper in the Journal of the American Medical Informatics Association (JAMIA) that reported on the state of the science of clinical decision support (CDS) for hospital bedside nurses. Their conclusion contained mixed news: CDS that targets decisions made by bedside nurses improved the processes and effectiveness of care, but the number of nurse decision-making research studies lagged behind physician decision-making CDS studies of CDS, obscuring the evidence to show positive change in patient outcomes.
How do you define nursing informatics?
Nursing informatics lies at the intersection of information science, nursing science and cognitive science. One component of informatics is the study and use of clinical decision support systems. The purpose of CDS is to make it simple for people to have what they need at the time and place of decision-making to deliver the best possible patient care.
Sheila M Gephart , PhD, RN
Tell us about your clinical decision support study.
When I was in practice, I noticed gaps in how we were making decisions in the neonatal intensive care unit and I wanted to help clinicians by providing them better systematic and convenient information about the context of care and the factors that put a baby at risk to develop complications. CDS has been shown to improve the process and outcomes of care delivered by physicians but we need more studies that target the decisions that nurses make. For the paper published in JAMIA, we wanted to discover what the state of the science was for bedside nursing CDS.
Tell us more about CDS for nurses.
Simply put, CDS matches patient characteristics to best recommended care and delivers reminders, alerts or advisory messages to support nursing care that aligns best with expert recommendations. The best and most effective CDS is built on data that comes directly from the electronic health record. It generates context and communicates a recommendation through an alert. So instead of communicating ‘This patient has an early warning score of nine and it’s high-risk,’ the message would say, ‘This patient’s early warning score is nine and you should do this.’ Even better, the message would be delivered directly to the clinician or set of clinicians who can act on the information.
What are some of the decisions nurses make that this work would benefit?
Nurses make decisions all the time. They’re assessing how at-risk a patient is for a fall, to develop an adverse complication, or to develop sepsis. They’re deciding how to prevent a patient from getting a complication they shouldn’t. One critical decision nurses make is about monitoring and communicating signs of a patient getting worse. CDS is especially good at making the decision about care more systematic, expert-informed and consistent. It keeps nurses from missing the simple signs, which is important because their work environments can be very fragmented, interruptive and rapidly changing.
What makes your study particularly unique?
Nurses put more information into the electronic health record (HER) than anybody else in the hospital and their needs are the least well met. So far, nurses get very little value for what they put in. In some situations, it has not been designed or adapted to help them do their job easier or more efficiently. With our paper, we showed how little evaluation of nursing CDS is available and how underdeveloped it is to meet nurses’ decision-making and ultimately patients’ needs. The message we came away with is that there’s a huge need for people to study this, and to develop CDS that meets CDS design best practices.
What’s the future of this project?
We proposed some very specific recommendations about what needs to be done to help design better decision support that is aligned with people’s workflow. We recommend expansion of nursing CDS, to integrate it into workflow and to allow shared views of CDS delivered across the health-care team (e.g. nurses to be able to see what CDS was offered to the physician for their patient and how they responded to it). Dr. Dunn-Lopez and I are also both individually developing CDS that targets nurses.
How will the results of your study impact nursing education?
It brings more visibility to the decisions that nurses make and how they need technology to support them to add value to the EHR for them. I’ve taught the methods for systematic reviews to my students and conducted others since then. Systematic reviews are important to make sense of a body of research and to identify next steps. This helps both PhD and DNP nursing students. They need to be able to take in the whole breadth of what’s going on, find the gap, and decide what to do next.
How is this project helping to build better futures?
When we support nursing decisions, we help them to do their work better, which can keep a patient healthy or even save their life. This project showed that more decision support is needed in nursing, especially in the pediatric and maternal child settings, where my work fits. It highlights opportunities to improve the value of electronic health records for nursing. As nursing informatics and CDS develop, trends are pointing toward better integration of EHRs with decision support – making their structure more open. The future is bright for nursing informatics!
Third-year online Doctor of Nursing Practice (DNP) psychiatric mental health nurse practitioner student; from Southern California
Why did you decide to pursue a nursing degree?
As a child, I was a ward of the court. From early on, I witnessed the mistreatment of those suffering from mental illnesses. As I got older and worked my way out of that environment, I felt an intense drive to try to position myself to make a difference. After working for over a decade as a behavioral health technician, I realized I could do much more if I returned to school to obtain an RN. My many years of behavioral health experience afforded me the ability to move into management positions fairly quickly and executive leadership within just four years. I realized I needed to continue my education and worked on my BSN. However, I felt that as an RN, even in executive leadership, I was still limited in my ability to influence policy affecting patient outcomes. I decided that I could make an even greater impact if I returned to school for my DNP.
What drew you to the UA College of Nursing?
I wanted to earn my DNP at a prestigious institution. The UA College of Nursing has a reputation for excellence in both education and research. My wife is a triple alumna and a true Wildcat. We knew we wanted to stay in Tucson, so it was a great opportunity to become an official Wildcat.
What features of your program are you especially passionate about?
I enjoy the discussions with my peers and faculty and learn a great deal from them. However, my passion lies, as always, in the clinical setting. Hands-on hours in the clinic seeing patients have been the highlight of the program for me.
Share your favorite memory from your time at the CON.
In the Spring 2017 semester, I did a focused exam with Dr. Kate Sheppard, the outcome of which would dictate whether or not I could continue in the program. I was a bundle of nerves -- sweating, shaking, heart racing. As I moved through the "patient visit" and examination, what I had learned thus far and the guidance I had received just started to flow naturally. I scored 100% on the focused exam, and I correctly diagnosed pulmonary embolism. This was an ah-ha moment for me, that I was going to be able to succeed in this program and that I really could do this.
How do you intend to Build Better Futures?
Initially, I intend to Build Better Futures by working as a provider and helping people in underserved populations. After gathering some practice experience, I can see myself moving back into executive leadership to help create policy that is beneficial for patients and their families. I will also continue to advocate for the integrated healthcare model, including the mind, body and spirit.
Newsletter: 2017 Issue 2
Sept. 1, 2017
Integrative Care for Older Adults as a Unique Learning Experience for UA Nursing Students
In mid-July, eight Master of Science for Entry to the profession of Nursing (MEPN) program students completed their first clinical rotations at The Hacienda at the River, the latest senior residential community initiated by the Watermark Retirement group. With a focus on independent living, assisted living and memory care communities, the goal at The Hacienda is for residents to advance their personal wellbeing in ways that resonate physically, spiritually and emotionally. The approach is a perfect match for a partnership with the University of Arizona College of Nursing – with its integrative health focus and one-of-a-kind Integrative Nursing Faculty Fellowship (INFF) – and provides a perfect opportunity for students to see how integrative therapies can become a larger part of their practice.
Along with engaging in the usual health-related assessments, over four days students immersed in new therapeutic experiences, such as physical therapy and equine therapy. According to their faculty coach, Dr. Kimberly Shea, “The administration and staff made sure we formed solid relationships and engaged in meaningful learning opportunities.” In tune with the UA College of Nursing partnership with the National Hartford Center of Gerontological Nursing Excellence, the experience wrapped up with several students indicating strong desire to work in such an environment. “That’s really nice,” says Dr. Shea, “because older adult care is an area for which skilled nurses are in high demand.”
Student Views of their Experience:
Yvette Eason
I had some idea of integrative health in terms of nutrition and meditation, but I hadn’t been exposed to the therapies at The Hacienda, like hand massage, guided imagery or equine therapy. I felt apprehensive about how the residents would respond to some of the therapies, but they’re actually really open and enjoyed what we did for them. I spent most of my time in assisted living where many of the residents are 90 years or older. I really enjoyed working with them, hearing their stories, talking with them.
Sherry Nguyen
I really like the way they’re incorporating alternative therapies rather than just going the pharmacological route. And the use of animal therapy was inspiring because animals can do amazing things for the body and the mind. Amazingly, I actually witnessed one resident drop his blood pressure by 30 mm Hg by just being in the presence of a horse. I also learned that an environment can really change a person’s health. If you are really satisfied with the environment that you’re in, it’s easier for you to heal or to stay motivated to engage in healthy behaviors. A lot of the residents were happy with the care that they received and I noticed that the residents all really got along with each other. They just seemed a lot more stress-free and I think that’s crucial for overall health.
Yaralyn Romero
I didn’t know too much about integrative care before this experience. Learning to incorporate therapies like mindfulness, guided imagery and therapeutic massage into the care that I was giving was really valuable. I was excited and a little bit nervous to finally get out of my bubble, shed my nervousness and provide hands-on care for actual patients – although at The Hacienda they’re called guests and residents rather than patients. I also appreciated the emphasis on self-care for staff, because compassion fatigue and burnout are an important issue in health care. I’m excited that I got this experience because I know that in health care there is pressure to move toward integrative healthcare and non-pharmacological options.
Taylor Valdez
My knowledge of integrative health going into this clinical rotation was very limited. Within a medical environment, using a holistic approach to healing typically does not go beyond therapeutic communication; being able to go beyond was invigorating. As a student, I consider being able to experience the environment at The Hacienda such a blessing. Not only is the atmosphere aesthetically pleasing, and the food divine, but the staff are incredibly kind. Working in memory care, I engaged in therapeutic equine sessions with the residents. This proved to be truly remarkable in the promotion of health. As I move forward with my nursing education, I will certainly take with me the therapeutic and evidence-based practices I have learned as an approach to hasten healing for my patients.
PhD candidate, expected graduation in August 2017; from South Africa
Why did you decide to pursue a nursing degree?
I was born and raised in rural South Africa, where health care services are either unavailable or inaccessible. When I was 12 years old I saw my mother lovingly take care of my late grandmother using traditional medicines from a medicine man. Without help or guidance, she did the best she could. After graduating from high school, I went to the local hospital and knocked at the door of “The Matron,” which is what they call the Chief Nursing Officer, and told her I wanted to be a nurse because I wanted to be able to better take care of my mother if she gets sick and build a clinic at my local village for all the villagers to get health care.
What drew you to the UA College of Nursing?
When I started at the University of Arizona College of Nursing it was for convenience. I was a full-time employee and a single mother raising my teenage son and had just moved to the United States. I was still struggling with understanding American culture, so it was a very challenging time. The College’s mission and values gave me comfort and motivation, especially its values of balance and social responsibility.
What features of your program are you especially passionate about?
My research topic was self-care behaviors of rural women post-invasive coronary interventions. Rural women and cardiovascular disease are my passion. Working with rural health expert, Dr. Sally Reel , and cardiovascular health expert, Dr. Anne Rosenfeld, was all I could ever ask for. To top it off, I had the opportunity to start my rural cardiovascular health career by working with rural populations during my dissertation.
Share your favorite memory from your time at the CON.
Attending RISE [Residential Intensive Summer Experience, an on-campus intensive for PhD and DNP students] was my favorite time in the whole program and I was very sad when I couldn’t attend anymore. To meet with my cohort, my professors and the IT people was always very exciting.
How do you intend to Build Better Futures?
For me, nursing is the center and the pillar of health care provision. Through research and teaching, I will make an impact on the nursing practice and nursing profession. Building a better nursing future is not only for nurses, but also for the populations receiving the nursing care. Heart disease is a number one killer worldwide, but most people do not know that. Empowering the new nursing generation to disseminate the knowledge they acquired to the populations they serve is the key to disease management, including lower mortality and morbidity rates. The one-size-fits-all approach to health care is not practical and rural populations’ perceptions of health are different from urban populations’ perceptions of health. New health innovations must be disseminated using methods that are suitable for specific populations and communities.
Meet Eric Smith, BSN Student
July 19, 2017
Eric Smith is a Bachelor of Science in Nursing (BSN) student at the University of Arizona College of Nursing and a UA Foundation scholarship recipient. He is also an eagle scout and a former firefighter.
Meet Ishmail Sillah, MEPN Student
July 14, 2017
During the 2014 University of Arizona College of Nursing Donor Appreciation Tea, Ishmail Sillah, a student in the Master's Entry into the Profession of Nursing (MEPN) program, shares how his experience growing up in war-torn Sierra Leone and having limited health care access inspired him to become a nurse.
