Evaluation of education initiatives to increase delivery of age-friendly care in retail clinics.

BACKGROUND: The Age-Friendly Health Systems model, encompassing four key elements (4Ms)-What Matters, Medication, Mentation, Mobility-is integral to delivering high-quality care to older adult patients. In May 2020, the MinuteClinic at CVS implemented the 4Ms model in all 1100+ store locations nationwide. To prepare healthcare providers to deliver 4Ms care, educational modules were developed to provide an understanding of the gerontology principles that support the 4Ms model of care. Our goal was to evaluate the effectiveness of these education modules on improving reliable 4Ms delivery during retail clinic visits. METHODS: Educational modules were provided to nurse practitioners and physician associates to complete in a self-directed manner. These included an orientation module with scenarios comparing usual care and 4Ms care, 12 monthly grand rounds focusing on 4Ms case studies, and 10 video vignettes on 4Ms integration. We examined the association between number of education modules completed with the average number of Ms delivered per visit (M-Score) using descriptive statistics and a generalized linear mixed-effects model. RESULTS: Over 70% of 2783 providers completed at least one education module. Rates of 4Ms care delivery were 1.37 (1.36-1.39, p < 0.001) times higher among those that completed an orientation course compared to those that did not. Higher uptake of education exhibited a dose-response relationship with rate ratios between 1.77 (1.74-1.80, p < 0.001) for 1-2 modules beyond orientation, up to 2.94 (2.90-2.99, p < 0.001) for eight or more modules. CONCLUSIONS: The self-directed learning environment (e.g., providers self-select the number and type of courses) reflects real-world variation in engagement. Despite this variation, significant improvements in 4Ms delivery were observed at any level of educational exposure, underscoring the value of prioritizing education time with quality improvement initiatives.

Promoting Type 1 Diabetes Self-care Management in the Hospital: Can It Be Done?

PURPOSE: The specific aim of the study was to determine whether there was an increased time in target glucose range for individuals with type 1 diabetes mellitus who were permitted to self-manage their insulin plan while hospitalized. DESIGN: A retrospective chart review was conducted of 60 inpatients with type 1 diabetes mellitus who met the criteria to self-manage their diabetes care with the use of their continuous subcutaneous insulin infusion pump or a multiple daily injection insulin regimen. A comparison of the 2 groups was examined to assess differences in glucose outcomes and glycemic stability. RESULTS: Seven hundred fifty-three glucose results were examined. The total number of hypoglycemic events in both groups was 37. The number of glucose values labeled as stable was 405, and the remaining 311 glucose values were categorized as hyperglycemic. There were no statistically significant differences in glucose levels between the 2 groups. CONCLUSION: No patients experienced severe hypoglycemia leading to cognitive impairment or severe hyperglycemia leading to diabetic ketoacidosis. The outcomes of this study suggest that diabetes self-management practices in select individuals hospitalized with type 1 diabetes mellitus can contribute to greater glucose stability and time in targeted glucose range.

Achievement of age-friendly health systems committed to care excellence designation in a convenient care health care system.

OBJECTIVE: To describe the implementation of the age-friendly health systems (AFHS) 4Ms Framework, an evidence-based framework to assess and act on "What Matters, Medication, Mentation and Mobility to deliver Age-Friendly health care for patients 65 and older", to achieve the Institute for Health care Improvement (IHI) Committed to Care Excellence recognition in a convenient care health system and test two novel implementation strategies. SETTING: The study was conducted in over 1100 convenient care clinics in 35 states and DC. MinuteClinics are located in community-based retail pharmacies in rural, suburban, and urban areas and staffed with approximately 3300 nurse practitioners and physician associates. DESIGN: In Year 1, the project used a quality improvement design, and in Year 2, a quasi-experimental implementation research design to pilot two strategies at the provider level (Virtual Clinic and Plan-Do-Study-Act (PDSA)). Statistical process control charts were used to assess changes in 4Ms documentation over time. Mixed-effects Poisson regression was used to assess the effectiveness of the pilot studies. DATA COLLECTION: The electronic health record (EHR) was enhanced to capture documentation of the AFHS 4Ms assessments and actions. A learning platform was created to teach and evaluate provider 4Ms competency, and the two data sources were merged into a registry. A formative evaluation was conducted using Tableau and reporting dashboards. FINDINGS: After 18 months and the implementation of 20 strategies to improve the uptake of the 4Ms, MinuteClinic achieved the IHI Committed to Care Excellence recognition. A significant increase over time in the reliable delivery of all 4Ms and each M component individually was found. For the research, there were significant improvements in the mean number of Ms delivered per visit (M-Score) in the Virtual Clinic (Incident Rate Ratio [IRR]: 2.47, p = 0.001) and PDSA (IRR: 3.08, p = 0.002) strategy intervention groups when compared to controls. CONCLUSIONS: Application of quality improvement and implementation methodologies contributed to the success of implementing age-friendly 4Ms evidence-based practice.

A quality improvement approach to develop an educational initiative for an age-friendly health system.

Authors describe a quality improvement approach to develop and pilot test educational materials with an aim to educate MinuteClinic providers in the provision of age-friendly care using the 4Ms Framework: What Matters, Medication, Mentation, Mobility. The team used surveys, focus groups and site visits to develop educational prototypes with Plan-Do-Study-Act iterative cycles to improve the education. Educational materials introduced providers to 4Ms assessment and evidence-based act on strategies for older adults in the convenient care setting. The education activities included an interactive orientation module comparing standard care to 4Ms care, 10 video vignettes with experts addressing gerontological topics, and 12 grand rounds presented monthly on topics applying the 4Ms with older adults. The information gained from the staff aided in the development and the iterative improvement of the materials. This article highlights the benefits of using a quality improvement approach in development of clinician education in provision of age-friendly care.

Prevalence and Components of Newborn Assessment Policies Related to Sudden Unexpected Postnatal Collapse.

OBJECTIVE: To describe, in a convenience sample, different hospitals' nursing care policies related to normal newborn assessment, to summarize common components of those policies related to sudden unexpected postnatal collapse (SUPC) of the newborn, and to correlate characteristics of the hospitals with the presence or absence of a normal newborn assessment policy. DESIGN: Descriptive evaluative design. SETTING: Hospital representatives were contacted to complete a questionnaire and provide a copy of their policies regarding normal newborn assessment. PARTICIPANTS: Representatives from 39 hospitals that provide maternal/newborn services within the United States completed the questionnaire and/or provided the investigator with a written nursing care policy for normal newborn assessment. INTERVENTION/MEASUREMENTS: Components of the hospitals' normal newborn assessment policies were evaluated according to the framework of recommended components outlined by the American Academy of Pediatrics in Feldman-Winter et al. (2016). RESULTS: The four components most often included in the policies submitted by 26 hospitals were maternal/newborn dyad assessments (n = 25, 96%), sequence of events postpartum (n = 15, 58%), monitoring (n = 9, 35%), and skin-to-skin contact procedures (n = 8, 30%). Differences were noted based on the size of the hospital as defined by the number of births and number of beds and also by the type of unit. CONCLUSION: Few policies in this study aligned with the recommended suggestions from the American Academy of Pediatrics outlined in Feldman-Winter et al. (2016). It is also important to note that these recommended suggestions relate to safe skin-to-skin contact and rooming-in practices, which may in turn affect the incidence of SUPC. There is much work to be done in terms of disseminating evidence and developing and implementing newborn assessment policies related to SUPC.

Maintaining vigilance to promote best outcomes for hospitalized elders.

This article presents contemporary evidence regarding the promotion of a culture of caring for hospitalized older persons through nursing vigilance. A summary of the literature regarding the need for vigilance, what to be vigilant about, and how vigilance can be enhanced for hospitalized older persons is provided, as well as recommendations for practice, education, research, and policy. Evidence indicates that vigilance is enhanced by having nurses who have specialized knowledge to differentiate normal aging from abnormal pathology, and who use point-of-care information, electronic health records, patient care information systems, and computerized adverse events detection systems to monitor symptoms and outcomes and prevent errors. The use of specialized models of patient care and adequate nurse-patient staffing also have been shown to prevent errors and improve patient outcomes.

Is caffeine excess part of your differential diagnosis?

The consumption of caffeine, and its effect on the human body, is a topic of ongoing debate. The average consumer may unwittingly consume excessive amounts of caffeine that may lead to adverse physiological side effects. Even the most astute clinician may miss caffeine-excess in the differential diagnosis. Therefore, a careful patient history, including a food and beverage diary, may be helpful in diagnosis of caffeine excess.

Treatment options alleviate female urge incontinence.

Urge incontinence affects a considerable percent of adult women, yet remains largely untreated. It is most often a chronic condition and can be debilitating when neglected. Advanced Practice Nurses need to be aware of incontinence in their patients, determine the underlying causes and individualize treatment to each patient. Several effective treatment options exist in managing urge incontinence, including behavioral therapy, pharmacologic therapy and surgical management. The clinician initiates and follows treatment regimens, and is ideally suited to provide patients with the education and motivation required for chronic therapy.

When bladder scans fail: three case studies.

This article contains three case studies describing patients who initially presented with complaints of symptoms consistent with urinary retention. Preliminary bladder scans confirmed this diagnosis; however, further workup revealed nonurologic causes for the patients' symptoms.