Nursing leadership and influence in practice domains at a Veterans Affairs Health Care System.

BACKGROUND: Studies in Veteran populations have examined disparities in health service use, care quality, outcomes and increased demands for behavioral health. PURPOSE: The purpose is to describe the development of nursing leadership roles that influenced practice improvements and demonstrated outcomes related to health disparities in a Veterans Affairs (VA) population over a 12-year period. METHODS: The Sundean and colleagues' concept analysis of nurse leadership influence was applied to frame the initiative process and impacts. DISCUSSION: Antecedents and processes that facilitated leadership development included mentorship, disparities expertise, partnerships, consultation, scholarship, dissemination, advocacy, education, and strong coauthor collaboration. Improvements and outcomes included access to services, improved health indicators, tools, workforce, funding, innovations, and nurse investigator studies, consistent with VA priorities and policy related to disparities and equity. Limitations and barriers were addressed. CONCLUSION: This initiative models' strategies to increase nurse leadership in health equity and care transformation in health systems and community practices.

An institution-wide faculty mentoring program at an academic health center with 6-year prospective outcome data.

BACKGROUND: There is discontent and turnover among faculty at US academic health centers because of the challenges in balancing clinical, research, teaching, and work-life responsibilities in the current healthcare environment. One potential strategy to improve faculty satisfaction and limit turnover is through faculty mentoring programs. METHODS: A Mentor Leadership Council was formed to design and implement an institution-wide faculty mentoring program across all colleges at an academic health center. The authors conducted an experimental study of the impact of the mentoring program using pre-intervention (2011) and 6-year (2017) post-intervention faculty surveys that measured the long-term effectiveness of the program. RESULTS: The percent of faculty who responded to the surveys was 45.9% (656/1428) in 2011 and 40.2% (706/1756) in 2017. For faculty below the rank of full professor, percent of faculty with a mentor (45.3% vs. 67.1%, P < 0.001), familiarity with promotion criteria (81.7% vs. 90.0%, P = 0.001), and satisfaction with department's support of career (75.6% vs. 84.7%, P = 0.002) improved. The percent of full professors serving as mentors also increased from 50.3% in 2011 to 68.0% in 2017 (P = 0.002). However, the percent of non-retiring faculty considering leaving the institution over the next 2 years increased from 18.8% in 2011 to 24.3% in 2017 (P = 0.02). CONCLUSIONS: Implementation of an institution-wide faculty mentoring program significantly improved metrics of career development and faculty satisfaction but was not associated with a reduction in the percent of faculty considering leaving the institution. This suggests the need for additional efforts to identify and limit factors driving faculty turnover.

Adult Children and the Transition of Aging Parents.

This study explores the experiences of adult children as they transition their functionally and/or cognitively declining aging parents from independent living to supervised housing. A qualitative grounded theory approach was used to chronicle the experiences of adult children as their caregiving responsibilities intensified and their parents' health declined. Purposive, snowball sampling was used to enlist adult children (n = 16) who were in the process of transitioning an aging parent from an independent living situation to one providing assistance with everyday care and tasks. Semi-structured telephone interviews were conducted and designed to follow a pattern of increased frailty of the parent(s) and escalating involvement of the adult child. Two major themes emerged from the data: Changing places and everlasting love. Adult children began to intervene when cognitive or physical declines compromised the safety and well-being of the older adult and began to assume responsibility for day-to-day needs. As disabilities intensified, adult children relied on siblings, friends, social services, and health care providers to assist in planning and implementing caregiving responsibilities. Deep respect and abiding love of the aging parent(s) sustained the adult child throughout the caregiving experience.

Appointment Reminders to Decrease 30-Day Readmission Rates to Inpatient Psychiatric Hospitals.

PURPOSE OF PROJECT: The purpose of this quality improvement project was to reduce 30-day readmission rates to inpatient psychiatric hospitals by standardizing discharge processes by including scheduling outpatient psychiatric appointments for all patients at discharge and also to include the mailing postal reminders to prompt patients to attend their first outpatient mental health appointment following treatment. PRIMARY PRACTICE SETTING: Inpatient psychiatric hospital. METHODOLOGY AND SAMPLE: The project design was an analysis of readmission data obtained both 3 months before and after implementation of the postal reminder letters. This project took place at a 50-bed inpatient psychiatric hospital in the southeastern United States that accepts male and female adult patients with mental health and substance abuse disorders. RESULTS: The implementation of an appointment reminder letter resulted in a slight decrease in 30-day readmission rates. The average readmission rate 3 months prior to implementation was 10%. The average readmission rate 3 months postdischarge was 9%. December 2015 was included in the postimplementation data. December historically has higher rates of 30-day readmissions at this facility. If this month had been excluded, more dramatic decrease in 30-day readmission rates could be observed. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: Future implications for case management practice could include the usage of reminder prompts via telephone communication or text messaging in conjunction with postal reminders. The psychiatric population can be particularly challenging when considering increased risk for readmission within 30 days and also the impending pay-for-performance quality measures, which are soon to be implemented. Measures should be taken now to ensure that readmission rates decrease, not only to promote better patient outcomes, but also as a cost-saving measure. Although many variables may contribute to the risk for 30-day readmission rates including medication noncompliance, lack of proper follow-up, as well as seasonal trends, the postal appointment reminder letters may further decrease 30-day readmission rates. Other care management strategies combined with reminder letters may further address barriers that may exist to not only improve patient outcomes, but also to further reduce readmission rates. It is also important to mention that there are further implications that could be directly contributed to specific social determinants of health specific to the psychiatric population. For example, access to prescribed medications and transportation to appointments should be addressed to further reduce readmission rates for this vulnerable population.

Increasing physical activity for veterans in the Mental Health Intensive Case Management Program: A community-based intervention.

AIMS AND OBJECTIVES: Individuals with severe mental illness (SMI), experience increased mortality-20 years greater disparity for men and 15 years greater disparity for women-compared to the general population (Thornicroft G. Physical health disparities and mental illness: The scandal of premature mortality. Br J Psychiatr. 2011;199:441-442). Numerous factors contribute to premature mortality in persons with SMI, including suicide and accidental death (Richardson RC, Faulkner G, McDevitt J, Skrinar GS, Hutchinson D, Piette JD. Integrating physical activity into mental health services for persons with serious mental illness. Psychiatr Serv. 2005;56(3):324-331; Thornicroft G. Physical health disparities and mental illness: The scandal of premature mortality. Br J Psychiatr. 2011;199:441-442), but research has shown that adverse health behaviors-including smoking, low rate of physical activity, poor diet, and high alcohol consumption-also significantly contribute to premature deaths (Jones J. Life expectancy in mental illness. Psychiatry Services. 2010. Retrieved from http://psychcentral.com/news/2010/07/13/life-expectancy-in-mental-illness). This quality improvement (QI) project sought to improve health and wellness for veterans in the Mental Health Intensive Case Management Program (MHICM), which is a community-based intensive program for veterans with SMI at risk for decompensation and frequent hospitalizations. At the time of this QI project, the program had 69 veterans who were assessed and treated weekly in their homes. The project introduced a pedometer steps intervention adapted from the VA MOVE! Program-a physical activity and weight management program-with the addition of personalized assistance from trained mental health professionals in the veteran's home environment. Because a large percentage of the veterans in the MHICM program had high blood pressure and increased weight, these outcomes were the focus of this project. Through mental health case management involvement and the comfort of their familiar living environment, veterans were assisted to meet their physical and mental health goals with a program that could easily be integrated into their daily lives. BACKGROUND: Healthy People 2020 developed goals to improve levels of physical activity and has ranked physical activity as a leading health indicator (US DHHS. Office of Disease Prevention and Health Promotion. Physical activity topic overview. In Healthy People 2020. 2016. Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/physical-activity). Individuals with SMI are significantly less active than the general population (Shor and Shalev, 2014). It is sometimes difficult for the average individual to obtain the recommended 10,000 steps and even more difficult for those with SMI. Lifestyle modifications, in particular diet and exercise, are recommended for improvement of chronic disease outcomes (US Preventive Services Counseling Task Force, 2016). The health benefits of physical activity for people with SMI are mixed (Pearsall R, Smith D, Pelosi A, Geddes J. Exercise therapy in adults with serious mental illness: A systematic review and meta-analysis. BMC Psychiatr. 2014;14:117). Some studies found significant physical health benefits, while others did not. However, according to a review by Soundy et al., physical exercise is shown to not only have physical benefits but also psychosocial benefits. One of the barriers that hinder participation in physical activities is accessibility (Shor and Shalev, 2014). Integrating a more personalized supported, and in-home pedometer program into mental healthcare should ensure better access to interventions that could possibly reverse the causes of premature death. METHODS: The program was offered to 69 veterans in the MHICM. Forty-nine agreed to start the program and 20 declined. Twenty-five clients actually started the program with 17 veterans completing it. Preimplementation data included collecting blood pressure and weight measures for all veterans in the MHICM program. Additionally, a focus group was held with case managers to obtain a group perspective on motivating veterans to participate in this program. Further, a teaching session was held to review pedometers use, the client video, the client booklet, methods for getting veterans started, and the progression of the walking intervention. The pedometer physical activity intervention continued for 2 months. At the end of the 2 months, aggregate de-identified data on number of steps, blood pressure, and weight were collected. At the end of the program, the data were reviewed, synthesized, and analyzed, being careful to account for potentially intervening conditions and other chronic illnesses. RESULTS: The postimplementation data revealed that the mean weight decreased by 9 lbs. The percentage of controlled blood pressure increased from 60 to 84, while the percentage of uncontrolled blood pressure decreased from 40 to 16. CONCLUSION: Implementation of a multiple component personalized exercise intervention program for veterans with SMI contributed to reduction in weight and blood pressure.

Improving Blood Pressure and Weight in Patients with Diabetes.

The purpose of this study was to improve healthcare outcomes by reducing blood pressure and weight in adult patients with diabetes at afederally qualified health center. NextGen electronic health record was used to review aggregate data of blood pressures and weight pre-intervention and post-intervention for women and men (N = 304) between 20 and 87 years of age with type 2 diabetes and a BMI : 30. Findings from this study showed that blood pressure and weight did not improve as anticipated using a variety of educational approaches and strategies within the study population. An interdisciplinary team approach should be undertaken to fully examine the problem so that the intervention is specifically targeted to the community population. With diabetes affecting nearly 1.7 million Americans annually, advanced practice nurses are in an ideal position to educate patients on the importance of healthy habits in order to reduce morbidity and mortality from diabetes.

Improving Glycemic Control in a Geriatric Population.

This quality improvement project evaluated whether offering a series of 5 structured interdisciplinary diabetic educational teaching sessions would improve glycemic control as measured by random blood sugars (RBS) in a Program of All-Inclusive Care for the Elderly (PACE). Five diabetic educational sessions were held over a 4-week period with 50 participants (N = 50). Data were analyzed and displayed using descriptive statistics and figures. Average RBS remained steady from 176.34 pre- to 175.52 post-intervention. In the Mini Mental State Exam (MMSE) group, representing a cognitive test score range of 24-30, RBS decreased from 184.6 to 162.80, with a slight increase in RBS in other groups. Mean RBS only decreased in the MMSE 24-30 test score range. African-American women and those in the community showed improved RBS. An interdisciplinary approach to care may offer benefits in subgroups of Type 2 Diabetes Mellitus (T2DM) patients and management of other chronic diseases in a geriatric population.

Scaffolding behavioral health concepts from more simple to complex builds NP students' competence.

BACKGROUND: Behavioral health disorders (psychiatric illness and substance abuse disorders) represent a significant burden across the nation's health care system. About one half of the problems that present in primary health care settings are behavioral in nature. There is urgent need to improve the integration of behavioral health care services into primary care. METHODS: The purpose of this paper is to describe how an asynchronous online graduate nurse practitioner program utilized a constructivist paradigm to creatively combine online problem based learning cases and on campus learning intensives to scaffold student learning. RESULTS: Student E-value scores were high and comments reflected improved knowledge, skill and comfort managing behavioral health problems in a primary care setting. CONCLUSION: This innovative model can serve as a template for other educational programs and improve student's ability to identify, manage and treat common behavioral health care problems that present in primary care settings.

Implementing school based telehealth for children with medical complexity.

PURPOSE: This quality improvement project aimed to improve parental experiences with healthcare delivery and collaborative health care offered at a school serving children with medical complexity (CMC) by implementing telehealth services. METHODS: Parents of students at an urban public charter school for CMC were surveyed before and after telehealth was implemented at the school for two months, and again one year later, using the Measure of Processes of Care (MPOC-20). RESULTS: Parental scores on the MPOC-20 were generally high both before and after the implementation of telehealth. There were no significant differences in the scores. Anecdotally, parent satisfaction with telehealth services was high. A review of the utilization of school-based telehealth during the 2015-2016 school year among 13 schools, including this unique school for CMC, revealed that the odds of having a telehealth visit at the school for CMC vs the other 12 schools was 23.8 (p value < 0.001; CL:11.2 to 50.6). CONCLUSION: Parental experiences with healthcare delivery were high both before and after the implementation of telehealth at an urban public charter school for CMC. Utilization of telehealth at the school for CMC was significantly higher than that of children enrolled in the program at 12 other schools. Further research is needed to evaluate parental experiences with school-based telehealth services.

Streamlining Appointment, Promotion, and Tenure Procedures to Promote Early-Career Faculty Success.

A critical component of the progression of a successful academic career is being promoted in rank. Early-career faculty are required to have an understanding of appointment, promotion, and tenure (APT) guidelines, but many factors often impede this understanding, thwarting a smooth and planned promotion pathway for professional advancement. This article outlines the steps taken by an APT committee to improve the promotion process from instructor to assistant professor. Six sigma's DMAIC improvement model was selected as the guiding operational framework to remove variation in the promotion process. After faculty handbook revisions were made, several checklists developed, and a process review rubric was implemented; recently promoted faculty were surveyed on satisfaction with the process. Faculty opinions captured in the survey suggest increased transparency in the process and perceived support offered by the APT committee. Positive outcomes include a strengthened faculty support framework, streamlined promotion processes, and improved faculty satisfaction. Changes to the APT processes resulted in an unambiguous and standardized pathway for successful promotion.

Implementation of Recovery Programming on an Inpatient Acute Psychiatric Unit and Its Impact on Readmission.

BACKGROUND: Recovery-oriented models of care are evidence based and have been shown to improve patient satisfaction and outcomes as well as decrease the percentage of readmissions to inpatient psychiatric units. METHODS: This quality improvement project was implemented on a 16-bed inpatient adult mental health unit in a Veterans Affairs Medical Center. Percentages of readmissions were compared throughout the course of implementation of the recovery model. Readmissions during the months of July-September were tabulated over 3 subsequent years and compared readmission percentages before recovery implementation, during the early stage of recovery implementation, and finally, during ongoing recovery implementation. RESULTS: A decrease in readmission percentages was seen with implementation of recovery-oriented care when comparing the same 3-month period over 3 years. CONCLUSION: After implementation of recovery-oriented care measures, there was a decrease in percentage of readmissions to the unit. In addition, this decrease was sustained and was shown to improve over time as recovery-oriented programming was further developed on the unit. These data suggest that Veterans Affairs Medical Centers should consider adding tools and procedures to successfully implement recovery programming on inpatient units and efforts should include direct involvement of patients in their own recovery journey, revision of policies and procedures to reflect the importance of recovery, thorough training of frontline staff regarding recovery principles, and transfer of recovery information directly from inpatient units to outpatient providers.

Improving Follow-Up for Failed Newborn Hearing Screening in Emirati Infants.

This column shares the best evidence-based strategies and innovative ideas on how to facilitate the learning and implementation of EBP principles and processes by clinicians as well as nursing and interprofessional students. Guidelines for submission are available at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1741-6787.

Depression Screening in Chronic Disease Management: A Worksite Health Promotion Initiative.

This pilot project aimed to improve depression symptoms and quality-of-life measures for individuals in a worksite disease management program. Two hundred forty-three individuals were invited to participate, out of which 69 enrolled. The participants had a history of diabetes, hypertension, or hyperlipidemia, and demonstrated depression using the Patient Health Questionnaire-9 (PHQ-9). The project consisted of counseling sessions provided every 2 to 4 weeks by a family nurse practitioner. PHQ-9 scores and those of an instrument that measures quality of life, the Veteran's Rand-12 (VR-12), were compared pre-intervention and post-intervention to evaluate the effectiveness of the project. PHQ-9 and VR-12 Mental Health Component (MHC) scores improved significantly after 3 months of nurse practitioner-led individual counseling sessions. This project demonstrated that depression screening and therapeutic management, facilitated by a nurse practitioner, can improve depression and perceived quality of life in individuals with hypertension, hyperlipidemia, or type 2 diabetes.

Implementing a Pediatric Fall Prevention Policy and Program.

Preventing patient falls begins with an accurate assessment of a patient's risk of falling followed by the initiation and continued evaluation of a fall prevention program based on patient-specific identified risks. Children have a normal tendency to fall based on developmental growth, and each child is different in physical and cognitive abilities. Falls may occur both in and out of the hospital setting. Prevention programs that have revealed the most favorable restuls include the use of a validated fall risk assessment tool. The Humpty Dumpty fall Scale is a screening tool specifically developed for pediatric patients to assess risk for fall. This project developed a pediatric fall prevention policy and implemented an inpatient pediatric fall prevention program. Pediatric staff contributed to the development of this policy and program by providing feedback, support, and cooperation, which was instrumental in the success of this program resulting in no falls after implementation.

Recognizing depression in late life.

Depression presents differently in older adults than in younger adults and frequently occurs with many chronic illnesses in later life, though it is not a normal part of aging. The astute practitioner will screen for depression in this population and appropriately treat to improve chronic illness management and quality of life in older adults.

Making the Move: A Mixed Research Integrative Review.

The purpose of this mixed research integrative review is to determine factors that influence relocation transitions for older adults who are considering a move from independent living to supervised housing, such as assisted living, using the Theory of Planned Behavior as a conceptual guide. PubMED, CINAHL, and PsychInfo databases were queried using key words: relocation, transition, older adults, and, elderly and time limited from 1992 to 2014. Sixteen articles were retained for review. The majority of articles, qualitative in design, reveal that older adults who comprehend the need to move and participate in the decision-making process of a relocation adjust to new living environments with fewer negative outcomes than older adults who experience a forced relocation. The few quantitative articles examined the elements of impending relocation using a variety of instruments but support the necessity for older adults to recognize the possibility of a future move and contribute to the relocation process. Additionally, the influence of family, friends, and health care providers provides the older adult with support and guidance throughout the process.