Jennifer H. Adams, EdM, MSN, RN, CPN
Incorporating clinical nurse specialists (CNS) into home healthcare models is crucial for agencies that want to be on the leading edge of healthcare. As an advanced practice nurse, the CNS adds value by working with patients, home healthcare clinicians, and systems to improve patient outcomes. The CNS is a change agent who directly impacts the client during transitions in and out of home care, throughout the course of chronic disease management, and by assuring quality care is delivered by field clinicians.
THE ROLE OF THE
Clinical Nurse Specialist in Home Healthcare T he clinical nurse specialist (CNS) is an untapped resource that home healthcare agencies should use to strengthen patient outcomes in a rapidly advancing healthcare industry. CNSs improve the quality of care delivered in inpatient settings (Ulch & Schmidt, 2013). Their experience and training equally prepare them to design and deliver improved home healthcare models of care. The Institute of Medicine’s The Future of Nursing report (2010) predicts extreme transformation of home healthcare in the next 10 years. Incorporating CNSs into home healthcare models will be crucial for agencies that want to be on the leading edge of healthcare transformation (National Association of Clinical Nurse Specialists [NACNS], 2012).
44
Volume 33
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Number 1
The CNS Role
CNSs are advanced practice nurses who work with patients, home healthcare clinicians, and healthcare systems to help patients meet their health goals. Based on experience and masters or doctoral education, CNSs focus their practice first on a population of patients, such as adult/ gerontology, women’s health, neonatal, pediatric, or mental health. They also bring clinical expertise in a specialty area, such as community health, oncology, or cardiology (APRN Joint Dialogue Group, 2008; National CNS Competency Task Force, 2010). CNSs practice seven core competencies and influence three groups, or spheres, which include the patient, the clinician, and the organization.
www.homehealthcarenow.org
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The CNS works to influence the health of individual patients, the practice of clinicians who care for patients, and the systems with which they interact to provide healthcare. The core competencies CNSs practice include direct care, consultation, systems leadership, collaboration, coaching, research interpretation, and ethical decision making, which includes moral agency and advocacy (National CNS Competency Task Force, 2010). The CNS is a change agent who uses advanced nursing practice to improve the healthcare system and nursing practice, ultimately for the purpose of empowering patients to manage their health appropriately thereby improving their quality of life (Foster et al., 2011; Moore & McQuestion, 2012).
CNSs in the Community Setting CNSs historically practiced in a variety of settings including hospital inpatient units, outpatient clinics, and community settings, such as public health and home healthcare. As the technological complexity of healthcare increased, nursing became more focused in the hospital setting (Robertson, 2004) and the CNS role progressively moved from the community into acute care settings. This shift culminated in the late 1990s, when community/ public health (CPH) was excluded as a population focus for advance practice nursing. As a result, many community CNS programs at universities closed (Robertson, 2004) further limiting the availability of CNSs in the community and home healthcare settings. Although the CPH population was not included in the advanced practice registered nurse licensing, accreditation, certification, and education model (APRN Joint Dialogue Group, 2008), there remained, briefly, a community CNS certification exam until the late 2000s (Doutrich, 2009). In 2005, there were 209 certified community health CNSs in the United States with 72% practicing in a community setting (Logan, 2005). When the community health CNS certification was phased out, the alternate certification for a community health specialty became the Advanced Public Health Nurse Board Certification. However, that certification was also retired and there is no longer a certificate exam for the CNS specializing in the CPH population (Doutrich, 2009; Madigan, 2012). There is no clear consensus about the role of the CPH nurse (Doutrich & Dotson, 2012). Is the
January 2015
Clinical nurse specialists are advanced practice nurses who work with patients, home healthcare clinicians, and healthcare systems to help patients meet their health goals.
focus population an individual living in a community or the collective residents of a community as a whole? In home healthcare, a subset of CPH nursing, the focus is an individual living in a community. A CNS practicing in home healthcare has both a population (adults, children, psychiatry/ mental health) and a specialty (home healthcare), regardless of the availability of a specialty certification exam.
CNSs in Home Healthcare The goal of home healthcare is to restore or maintain the highest possible level of patient independence (Murkofsky & Alston, 2009), which requires various methods of providing care and coordination across multiple systems. CNSs are trained to approach healthcare on a continuum from the individual to the organization and larger community. The core competencies of leadership, consultation, health management, advocacy, and collaboration uniquely qualify CNSs to work with home healthcare patients (Robertson & Baldwin, 2007). Below is a review of how CNSs can use their competencies to impact the delivery of home healthcare including client transitions, chronic disease management, and quality assurance. Figure 1 summarizes the integration of home care elements with CNS spheres of influence and competencies. Patient Transitions
Patients are transitioning from acute care to home to independence with more complex health and social needs than ever before (Ratcliff, 2007). CNSs use expert relationship building skills to establish trust. Sensitivity to patients and families encourages incorporation of their preferences and culture into their care. This, in turn, enhances the effectiveness of their healthcare and addresses their social needs (Ulch & Schmidt, 2013). Using
Home Healthcare Now
45
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
these holistic, relationship-based approaches to establish patient and family plans of care will facilitate transitions through home healthcare from admission to discharge (Ulch & Schmidt, 2013), especially in cases with particularly complex conditions requiring highly skilled interventions. CNSs can contribute their advanced assessment skills (DeFlon, 2012) and understanding of current, evidence-based interventions (Madigan, 2012) to the care planning process. A higher level of understanding of assessment, interventions, and patient-centered models of care positions the CNS to be a powerful advocate for client needs during times of transition. Transitioning complex patients after discharge from hospitals or skilled nursing facilities into home healthcare takes a great deal of collaboration, a skill at which CNSs are quite adept. Coordinating orders, equipment, and supplies between primary and specialty care providers, durable medical equipment and respiratory companies, community supports (volunteers, community organization, utility companies, etc.),
and payer sources are areas of home healthcare transitions (Madigan, 2012) that capitalize on the CNS’s ability to collaborate with multiple entities to meet complex client needs. Chronic Disease Management
Many home healthcare patients receive episodic visits with the goal of meeting short-term health goals. However, because of increasingly complex needs among the elderly as well as pediatric populations (who are living longer than ever before with previously fatal disease that can now be managed), home healthcare clinicians need to be prepared for long-term management of chronic diseases. Home visits will be used increasingly for chronic disease management (Madigan, 2012) and it is likely that private duty nursing will be increasingly available as an alternative to facilitybased long-term care. Assessment, consultation, coaching, advocacy, and collaboration are strengths CNSs bring to chronic disease management for the home healthcare patient. The CNS’s advanced assessment skills enhance identification of subtle condition changes, which can trigger early intervention to preSphere: Sphere: vent further deterioration, Clinicians Client Competency: emergency department visCoaching its, and readmission to the Competency: Collaboration Competency: hospital (NACNS, 2013a). Direct Care Ethical Decision Consultant The CNS is equipped to Making Advocacy Research Home Care coach patients to change Element: Home Care Element: behaviors and improve Home Care Clinician Education Element: Collaboration health (NACNS, 2013a). & Competency Chronic Desease Assessment Meeting patients in their Consulting with Management Care Planning Field Clinicians natural home environment Admission & Discharge where they are more enPlanning Advocacy gaged, and empowering them to take control of their health behaviors is a way Sphere: to increase self-manageOrganization ment and accountability of Home Care Element: Competency: chronic health conditions Quality Systems Leadership (Ulch & Schmidt, 2013). Improvement The CNS is a professional Policies & link between the primary Procedures care provider, who prescribes interventions for chronic disease manageFigure 1. Home care elements integrated with clinical nurse specialist ment, and the patient, who spheres of influence and competencies. Source: Developed by the author. implements those recom-
46
Volume 33
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Number 1
www.homehealthcarenow.org
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
mendations (NACNS, 2012). The CNS who meets with patients in their homes may have a more personal relationship with the client and can relate information about culture, lifestyle, and barriers to care to the primary care provider that might not be obtained in an office setting (McGuire et al., 2008). Barriers to care may include housing, transportation, financial, or cognitive limitations as well as enabling relationships. When a CNS accompanies a client to a medical provider visit, the care plan and implementation of interventions at home are strengthened (Ulch & Schmidt, 2013). As an expert collaborator, the CNS can bring together patient, primary care provider, and other resources such as transportation, supply companies, and pharmacies (Ulch & Schmidt, 2013) to facilitate the implementation of interventions and referrals (DeFlon, 2012; Moore & McQuestion, 2012).
Case Study Conner is a 7-year-old who was hit by a car. He has quadriplegia, a tracheostomy that requires mechanical ventilation, and a gastrostomy tube. He requires aggressive respiratory toileting, bowel management, and frequent urinary catheterization. Kathryn, a clinical nurse specialist with the home care agency, works collaboratively with the hospital social worker to plan for Conner’s complex needs and transition home. Kathryn meets with Conner and his family to learn their goals and preferences and build trust and rapport. After assessing the family’s home, she works with Conner’s parents and equipment companies to arrange the environment to best meet Conner’s needs while maintaining the routines and culture of the family. Kathryn reviews guidelines for the care of children with spinal cord injuries and collaborates with Conner’s pediatric specialists to develop a comprehensive, individualized care plan based on current evidence. Kathryn then assesses the training and experience of each nurse who will work with Conner to ensure a goodness of fit. Kathryn plans training for clinicians to review the pathophysiology that determines the interventions in Conner’s care plan and the assessments necessary to monitor progress toward his goals. She also facilitates trainings led by Conner’s therapists to ensure nurses are safely continuing his therapy regimen. After Conner’s transition home, Kathryn frequently visits the family and nurses to supervise implementation of the care plan. She regularly collects data to monitor Conner’s infection rate, skin integrity, adherence to the care plan, and progress toward his goals, implementing improvements and revising policies and procedures as needed. She works with Conner’s family, his team of specialists, and many school professionals to revise the care plan so he can attain his goal of returning to school. As Conner’s needs change, Kathryn coaches home healthcare clinicians and the family to provide quality care and advocate for services to meet his needs.
January 2015
A higher level of understanding of assessment, interventions, and patient-centered models of care positions the clinical nurse specialist to be a powerful advocate for client needs during times of transition.
Quality Assurance
Assuring that the highest quality care is provided to all patients involves professional development of field clinicians, evidence-based practice guidelines, and continual monitoring and improvement of outcomes. CNSs trained in coaching, consultation, collaboration, research interpretation, and systems leadership are strong candidates to assure the delivery of quality home healthcare. With an advanced understanding of patients’ health needs, CNSs can expertly match field clinicians to patients. CNSs can ensure goodness of fit by first providing education to field clinicians through individualized training or collaborating with hospital and vendor trainers (Ratcliff, 2007). The CNS’s abilities to consult and coach are a great asset to field clinicians. The CNS can demonstrate advanced assessment (DeFlon, 2012) and collaborate with field clinicians to problem solve clinical concerns. CNSs also are well equipped to assess nursing performance (DeFlon, 2012) and provide coaching and mentoring as well as education to improve care delivered. Policies, procedures, and care plans should be based on the most current and highest quality evidence. CNSs are trained to evaluate and interpret research and other evidence to determine best practice (NACNS, 2013a). For example, the CNS can use evidence-based practice models to determine the most appropriate techniques to clean and reuse home equipment (Ratcliff, 2007) or how new technologies can be safely deployed in a home setting (McClelland et al., 2013). Knowledge of evidence-based practice and research interpretation skills are also critical to support quality outcomes. As organizational leaders and systems change agents, CNSs are prepared to identify and monitor pertinent outcomes as well as lead collaborative efforts to
Home Healthcare Now
47
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REFERENCES
The clinical nurse specialist is equipped to coach patients to change behaviors and improve health.
improve outcomes (NACNS, 2012). CNSs are translators of research and can ensure use of best practices by field clinicians.
Implications With home healthcare identified as one necessary component of chronic disease management (Duckett, 2012), CNSs will increasingly add value to home healthcare agencies as well as to the larger healthcare system (Moore & McQuestion, 2012). CNSs have skills that can empower patients to take control of their healthcare and strengthen collaborations between patients and medical providers. Coaching and education from CNSs empower patients to be more adherent to plans of care and identify condition changes more quickly (Mayo et al., 2010). By helping patients change their health behaviors to increase adherence, the CNS reduces the costs of healthcare because early primary care decreases unnecessary emergency room visits, hospitalizations, length of stay, as well as out-of-pocket expenses for patients (NACNS, 2013b; Ulch & Schmidt, 2013). The impact of a CNS is greatest when they are involved in the early stages of diagnosis and with patients and families with limited resources (Moore & McQuestion, 2012). This supports using a CNS as a consultant available to field clinicians and clinical managers as needed to address issues related to complex medical and social cases. As the healthcare industry rapidly transforms, so must the home healthcare agency. Including CNSs in the home healthcare model will improve client outcomes by enhancing quality care, client transitions, and management of chronic diseases. Jennifer H. Adams, EdM, MSN, RN, CPN, is an Instructor, Delaware Technical and Community College, Georgetown, Delaware. The author declares no conflicts of interest. Address for correspondence: Jennifer H. Adams, EdM, MSN, RN, CPN ([email protected]). DOI:10.1097/NHH.0000000000000174
48
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APRN Joint Dialogue Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus_Model_for_ APRN_Regulation_July_2008.pdf DeFlon, S. (2012). The role of the clinical nurse specialist as clinician and advocate in a primary health care clinic. Creative Nursing, 18(3), 104-108. Doutrich, D. (2009). Community graduates no longer have option of CNS exam. Clinical Nurse Specialist, 23(1), 7-8. Doutrich, D., & Dotson, J. A. (2012). The future of the populationfocused, public health clinical nurse specialist. Nursing Clinics of North America, 47(2), 305-313. Duckett, K. (2012). Views on the future of nursing and home healthcare: The future of nursing in home healthcare is now. Home Healthcare Nurse, 30(3), 145-148. Foster, J., Clark, A. P., Heye, M. L., Rosenow, D. J., Baldwin, K., Villagomez, E. T., …, Ward, S. (2011). Differentiating the CNS and CNL roles. Nursing Management, 42(1), 51-54. Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies of Science. Logan, L. (2005). The practice of certified community health CNSs. Clinical Nurse Specialist, 19(1), 43-48. Madigan, E. A. (2012). Views on the future of nursing and home healthcare: The future of nursing for home healthcare. Home Healthcare Nurse, 30(3), 149-151. Mayo, A. M., Omery, A., Agocs-Scott, L. M., Khaghani, F., Meckes, P. G., Moti, N., …, Cuenca, E. (2010). Clinical nurse specialist practice patterns. Clinical Nurse Specialist, 24(2), 60-68. McClelland, M., McCoy, M. A., & Burson, R. (2013). Clinical nurse specialists: Then, now, and the future of the profession. Clinical Nurse Specialist, 27(2), 96-102. McGuire, A., Newman, A., & McTernan, S. E. (2008). Recent research in pediatrics: Implications for home health nursing. Home Healthcare Nurse, 26(2), 91-95. Moore, J., & McQuestion, M. (2012). The clinical nurse specialist in chronic diseases. Clinical Nurse Specialist, 26(3), 149-163. Murkofsky, R. L., & Alston, K. (2009). The past, present, and future of skilled home health agency care. Clinics in Geriatric Medicine, 25(1), 1-17. National Association of Clinical Nurse Specialists. (2012). The National Association of Clinical Nurse Specialists (NACNS) response to the Institute of Medicine’s Future of Nursing report. Retrieved from http://www.nacns.org/docs/IOM-Recommendations1203.pdf National Association of Clinical Nurse Specialists. (2013a). Impact of the clinical nurse specialist role on the costs and quality of health care. Retrieved from http://www.nacns.org/docs/ CNSOutcomes131204.pdf National Association of Clinical Nurse Specialists. (2013b). NACNS position statement on the importance of the clinical nurse specialist role in care coordination. Retrieved from http://www. nacns.org/docs/PositionOnCNSCoordinate.pdf National CNS Competency Task Force. (2010). Clinical nurse specialist core competencies. Retrieved from http://www.nacns.org/ docs/CNSCoreCompetenciesBroch.pdf Ratcliff, J. D. (2007). Home health admission and care of a pediatric ventilator-dependent client. Home Healthcare Nurse, 25(1), 35-40. Robertson, J. F. (2004). Does advanced community/public health nursing practice have a future? Public Health Nursing, 21(5), 495-500. Robertson, J. F., & Baldwin, K. B. (2007). Advanced practice role characteristics of the community/public health nurse specialist. Clinical Nurse Specialist, 21(5), 250-254. Ulch, P. A. O., & Schmidt, M. M. (2013). Clinical nurse specialist as community-based nurse case manager: Integral to achieving the triple aim of healthcare. Nurse Leader, 11(3), 32-35. Retrieved from http://www.nurseleader.com/article/ S1541-4612%2813%2900075-X/abstract
www.homehealthcarenow.org
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Incorporating clinical nurse specialists (CNS) into home healthcare models is crucial for agencies that want to be on the leading edge of healthcare. As an advanced practice nurse, the CNS adds value by working with patients, home healthcare clinicians, and systems to improve patient outcomes. The CNS is a change agent who directly impacts the client during transitions in and out of home care, throughout the course of chronic disease management, and by assuring quality care is delivered by field clinicians.
THE ROLE OF THE
Clinical Nurse Specialist in Home Healthcare T he clinical nurse specialist (CNS) is an untapped resource that home healthcare agencies should use to strengthen patient outcomes in a rapidly advancing healthcare industry. CNSs improve the quality of care delivered in inpatient settings (Ulch & Schmidt, 2013). Their experience and training equally prepare them to design and deliver improved home healthcare models of care. The Institute of Medicine’s The Future of Nursing report (2010) predicts extreme transformation of home healthcare in the next 10 years. Incorporating CNSs into home healthcare models will be crucial for agencies that want to be on the leading edge of healthcare transformation (National Association of Clinical Nurse Specialists [NACNS], 2012).
44
Volume 33
|
Number 1
The CNS Role
CNSs are advanced practice nurses who work with patients, home healthcare clinicians, and healthcare systems to help patients meet their health goals. Based on experience and masters or doctoral education, CNSs focus their practice first on a population of patients, such as adult/ gerontology, women’s health, neonatal, pediatric, or mental health. They also bring clinical expertise in a specialty area, such as community health, oncology, or cardiology (APRN Joint Dialogue Group, 2008; National CNS Competency Task Force, 2010). CNSs practice seven core competencies and influence three groups, or spheres, which include the patient, the clinician, and the organization.
www.homehealthcarenow.org
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The CNS works to influence the health of individual patients, the practice of clinicians who care for patients, and the systems with which they interact to provide healthcare. The core competencies CNSs practice include direct care, consultation, systems leadership, collaboration, coaching, research interpretation, and ethical decision making, which includes moral agency and advocacy (National CNS Competency Task Force, 2010). The CNS is a change agent who uses advanced nursing practice to improve the healthcare system and nursing practice, ultimately for the purpose of empowering patients to manage their health appropriately thereby improving their quality of life (Foster et al., 2011; Moore & McQuestion, 2012).
CNSs in the Community Setting CNSs historically practiced in a variety of settings including hospital inpatient units, outpatient clinics, and community settings, such as public health and home healthcare. As the technological complexity of healthcare increased, nursing became more focused in the hospital setting (Robertson, 2004) and the CNS role progressively moved from the community into acute care settings. This shift culminated in the late 1990s, when community/ public health (CPH) was excluded as a population focus for advance practice nursing. As a result, many community CNS programs at universities closed (Robertson, 2004) further limiting the availability of CNSs in the community and home healthcare settings. Although the CPH population was not included in the advanced practice registered nurse licensing, accreditation, certification, and education model (APRN Joint Dialogue Group, 2008), there remained, briefly, a community CNS certification exam until the late 2000s (Doutrich, 2009). In 2005, there were 209 certified community health CNSs in the United States with 72% practicing in a community setting (Logan, 2005). When the community health CNS certification was phased out, the alternate certification for a community health specialty became the Advanced Public Health Nurse Board Certification. However, that certification was also retired and there is no longer a certificate exam for the CNS specializing in the CPH population (Doutrich, 2009; Madigan, 2012). There is no clear consensus about the role of the CPH nurse (Doutrich & Dotson, 2012). Is the
January 2015
Clinical nurse specialists are advanced practice nurses who work with patients, home healthcare clinicians, and healthcare systems to help patients meet their health goals.
focus population an individual living in a community or the collective residents of a community as a whole? In home healthcare, a subset of CPH nursing, the focus is an individual living in a community. A CNS practicing in home healthcare has both a population (adults, children, psychiatry/ mental health) and a specialty (home healthcare), regardless of the availability of a specialty certification exam.
CNSs in Home Healthcare The goal of home healthcare is to restore or maintain the highest possible level of patient independence (Murkofsky & Alston, 2009), which requires various methods of providing care and coordination across multiple systems. CNSs are trained to approach healthcare on a continuum from the individual to the organization and larger community. The core competencies of leadership, consultation, health management, advocacy, and collaboration uniquely qualify CNSs to work with home healthcare patients (Robertson & Baldwin, 2007). Below is a review of how CNSs can use their competencies to impact the delivery of home healthcare including client transitions, chronic disease management, and quality assurance. Figure 1 summarizes the integration of home care elements with CNS spheres of influence and competencies. Patient Transitions
Patients are transitioning from acute care to home to independence with more complex health and social needs than ever before (Ratcliff, 2007). CNSs use expert relationship building skills to establish trust. Sensitivity to patients and families encourages incorporation of their preferences and culture into their care. This, in turn, enhances the effectiveness of their healthcare and addresses their social needs (Ulch & Schmidt, 2013). Using
Home Healthcare Now
45
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
these holistic, relationship-based approaches to establish patient and family plans of care will facilitate transitions through home healthcare from admission to discharge (Ulch & Schmidt, 2013), especially in cases with particularly complex conditions requiring highly skilled interventions. CNSs can contribute their advanced assessment skills (DeFlon, 2012) and understanding of current, evidence-based interventions (Madigan, 2012) to the care planning process. A higher level of understanding of assessment, interventions, and patient-centered models of care positions the CNS to be a powerful advocate for client needs during times of transition. Transitioning complex patients after discharge from hospitals or skilled nursing facilities into home healthcare takes a great deal of collaboration, a skill at which CNSs are quite adept. Coordinating orders, equipment, and supplies between primary and specialty care providers, durable medical equipment and respiratory companies, community supports (volunteers, community organization, utility companies, etc.),
and payer sources are areas of home healthcare transitions (Madigan, 2012) that capitalize on the CNS’s ability to collaborate with multiple entities to meet complex client needs. Chronic Disease Management
Many home healthcare patients receive episodic visits with the goal of meeting short-term health goals. However, because of increasingly complex needs among the elderly as well as pediatric populations (who are living longer than ever before with previously fatal disease that can now be managed), home healthcare clinicians need to be prepared for long-term management of chronic diseases. Home visits will be used increasingly for chronic disease management (Madigan, 2012) and it is likely that private duty nursing will be increasingly available as an alternative to facilitybased long-term care. Assessment, consultation, coaching, advocacy, and collaboration are strengths CNSs bring to chronic disease management for the home healthcare patient. The CNS’s advanced assessment skills enhance identification of subtle condition changes, which can trigger early intervention to preSphere: Sphere: vent further deterioration, Clinicians Client Competency: emergency department visCoaching its, and readmission to the Competency: Collaboration Competency: hospital (NACNS, 2013a). Direct Care Ethical Decision Consultant The CNS is equipped to Making Advocacy Research Home Care coach patients to change Element: Home Care Element: behaviors and improve Home Care Clinician Education Element: Collaboration health (NACNS, 2013a). & Competency Chronic Desease Assessment Meeting patients in their Consulting with Management Care Planning Field Clinicians natural home environment Admission & Discharge where they are more enPlanning Advocacy gaged, and empowering them to take control of their health behaviors is a way Sphere: to increase self-manageOrganization ment and accountability of Home Care Element: Competency: chronic health conditions Quality Systems Leadership (Ulch & Schmidt, 2013). Improvement The CNS is a professional Policies & link between the primary Procedures care provider, who prescribes interventions for chronic disease manageFigure 1. Home care elements integrated with clinical nurse specialist ment, and the patient, who spheres of influence and competencies. Source: Developed by the author. implements those recom-
46
Volume 33
|
Number 1
www.homehealthcarenow.org
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
mendations (NACNS, 2012). The CNS who meets with patients in their homes may have a more personal relationship with the client and can relate information about culture, lifestyle, and barriers to care to the primary care provider that might not be obtained in an office setting (McGuire et al., 2008). Barriers to care may include housing, transportation, financial, or cognitive limitations as well as enabling relationships. When a CNS accompanies a client to a medical provider visit, the care plan and implementation of interventions at home are strengthened (Ulch & Schmidt, 2013). As an expert collaborator, the CNS can bring together patient, primary care provider, and other resources such as transportation, supply companies, and pharmacies (Ulch & Schmidt, 2013) to facilitate the implementation of interventions and referrals (DeFlon, 2012; Moore & McQuestion, 2012).
Case Study Conner is a 7-year-old who was hit by a car. He has quadriplegia, a tracheostomy that requires mechanical ventilation, and a gastrostomy tube. He requires aggressive respiratory toileting, bowel management, and frequent urinary catheterization. Kathryn, a clinical nurse specialist with the home care agency, works collaboratively with the hospital social worker to plan for Conner’s complex needs and transition home. Kathryn meets with Conner and his family to learn their goals and preferences and build trust and rapport. After assessing the family’s home, she works with Conner’s parents and equipment companies to arrange the environment to best meet Conner’s needs while maintaining the routines and culture of the family. Kathryn reviews guidelines for the care of children with spinal cord injuries and collaborates with Conner’s pediatric specialists to develop a comprehensive, individualized care plan based on current evidence. Kathryn then assesses the training and experience of each nurse who will work with Conner to ensure a goodness of fit. Kathryn plans training for clinicians to review the pathophysiology that determines the interventions in Conner’s care plan and the assessments necessary to monitor progress toward his goals. She also facilitates trainings led by Conner’s therapists to ensure nurses are safely continuing his therapy regimen. After Conner’s transition home, Kathryn frequently visits the family and nurses to supervise implementation of the care plan. She regularly collects data to monitor Conner’s infection rate, skin integrity, adherence to the care plan, and progress toward his goals, implementing improvements and revising policies and procedures as needed. She works with Conner’s family, his team of specialists, and many school professionals to revise the care plan so he can attain his goal of returning to school. As Conner’s needs change, Kathryn coaches home healthcare clinicians and the family to provide quality care and advocate for services to meet his needs.
January 2015
A higher level of understanding of assessment, interventions, and patient-centered models of care positions the clinical nurse specialist to be a powerful advocate for client needs during times of transition.
Quality Assurance
Assuring that the highest quality care is provided to all patients involves professional development of field clinicians, evidence-based practice guidelines, and continual monitoring and improvement of outcomes. CNSs trained in coaching, consultation, collaboration, research interpretation, and systems leadership are strong candidates to assure the delivery of quality home healthcare. With an advanced understanding of patients’ health needs, CNSs can expertly match field clinicians to patients. CNSs can ensure goodness of fit by first providing education to field clinicians through individualized training or collaborating with hospital and vendor trainers (Ratcliff, 2007). The CNS’s abilities to consult and coach are a great asset to field clinicians. The CNS can demonstrate advanced assessment (DeFlon, 2012) and collaborate with field clinicians to problem solve clinical concerns. CNSs also are well equipped to assess nursing performance (DeFlon, 2012) and provide coaching and mentoring as well as education to improve care delivered. Policies, procedures, and care plans should be based on the most current and highest quality evidence. CNSs are trained to evaluate and interpret research and other evidence to determine best practice (NACNS, 2013a). For example, the CNS can use evidence-based practice models to determine the most appropriate techniques to clean and reuse home equipment (Ratcliff, 2007) or how new technologies can be safely deployed in a home setting (McClelland et al., 2013). Knowledge of evidence-based practice and research interpretation skills are also critical to support quality outcomes. As organizational leaders and systems change agents, CNSs are prepared to identify and monitor pertinent outcomes as well as lead collaborative efforts to
Home Healthcare Now
47
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
REFERENCES
The clinical nurse specialist is equipped to coach patients to change behaviors and improve health.
improve outcomes (NACNS, 2012). CNSs are translators of research and can ensure use of best practices by field clinicians.
Implications With home healthcare identified as one necessary component of chronic disease management (Duckett, 2012), CNSs will increasingly add value to home healthcare agencies as well as to the larger healthcare system (Moore & McQuestion, 2012). CNSs have skills that can empower patients to take control of their healthcare and strengthen collaborations between patients and medical providers. Coaching and education from CNSs empower patients to be more adherent to plans of care and identify condition changes more quickly (Mayo et al., 2010). By helping patients change their health behaviors to increase adherence, the CNS reduces the costs of healthcare because early primary care decreases unnecessary emergency room visits, hospitalizations, length of stay, as well as out-of-pocket expenses for patients (NACNS, 2013b; Ulch & Schmidt, 2013). The impact of a CNS is greatest when they are involved in the early stages of diagnosis and with patients and families with limited resources (Moore & McQuestion, 2012). This supports using a CNS as a consultant available to field clinicians and clinical managers as needed to address issues related to complex medical and social cases. As the healthcare industry rapidly transforms, so must the home healthcare agency. Including CNSs in the home healthcare model will improve client outcomes by enhancing quality care, client transitions, and management of chronic diseases. Jennifer H. Adams, EdM, MSN, RN, CPN, is an Instructor, Delaware Technical and Community College, Georgetown, Delaware. The author declares no conflicts of interest. Address for correspondence: Jennifer H. Adams, EdM, MSN, RN, CPN ([email protected]). DOI:10.1097/NHH.0000000000000174
48
Volume 33
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APRN Joint Dialogue Group. (2008). Consensus model for APRN regulation: Licensure, accreditation, certification & education. Retrieved from https://www.ncsbn.org/Consensus_Model_for_ APRN_Regulation_July_2008.pdf DeFlon, S. (2012). The role of the clinical nurse specialist as clinician and advocate in a primary health care clinic. Creative Nursing, 18(3), 104-108. Doutrich, D. (2009). Community graduates no longer have option of CNS exam. Clinical Nurse Specialist, 23(1), 7-8. Doutrich, D., & Dotson, J. A. (2012). The future of the populationfocused, public health clinical nurse specialist. Nursing Clinics of North America, 47(2), 305-313. Duckett, K. (2012). Views on the future of nursing and home healthcare: The future of nursing in home healthcare is now. Home Healthcare Nurse, 30(3), 145-148. Foster, J., Clark, A. P., Heye, M. L., Rosenow, D. J., Baldwin, K., Villagomez, E. T., …, Ward, S. (2011). Differentiating the CNS and CNL roles. Nursing Management, 42(1), 51-54. Institute of Medicine. (2010). The Future of Nursing: Leading Change, Advancing Health. Washington, DC: National Academies of Science. Logan, L. (2005). The practice of certified community health CNSs. Clinical Nurse Specialist, 19(1), 43-48. Madigan, E. A. (2012). Views on the future of nursing and home healthcare: The future of nursing for home healthcare. Home Healthcare Nurse, 30(3), 149-151. Mayo, A. M., Omery, A., Agocs-Scott, L. M., Khaghani, F., Meckes, P. G., Moti, N., …, Cuenca, E. (2010). Clinical nurse specialist practice patterns. Clinical Nurse Specialist, 24(2), 60-68. McClelland, M., McCoy, M. A., & Burson, R. (2013). Clinical nurse specialists: Then, now, and the future of the profession. Clinical Nurse Specialist, 27(2), 96-102. McGuire, A., Newman, A., & McTernan, S. E. (2008). Recent research in pediatrics: Implications for home health nursing. Home Healthcare Nurse, 26(2), 91-95. Moore, J., & McQuestion, M. (2012). The clinical nurse specialist in chronic diseases. Clinical Nurse Specialist, 26(3), 149-163. Murkofsky, R. L., & Alston, K. (2009). The past, present, and future of skilled home health agency care. Clinics in Geriatric Medicine, 25(1), 1-17. National Association of Clinical Nurse Specialists. (2012). The National Association of Clinical Nurse Specialists (NACNS) response to the Institute of Medicine’s Future of Nursing report. Retrieved from http://www.nacns.org/docs/IOM-Recommendations1203.pdf National Association of Clinical Nurse Specialists. (2013a). Impact of the clinical nurse specialist role on the costs and quality of health care. Retrieved from http://www.nacns.org/docs/ CNSOutcomes131204.pdf National Association of Clinical Nurse Specialists. (2013b). NACNS position statement on the importance of the clinical nurse specialist role in care coordination. Retrieved from http://www. nacns.org/docs/PositionOnCNSCoordinate.pdf National CNS Competency Task Force. (2010). Clinical nurse specialist core competencies. Retrieved from http://www.nacns.org/ docs/CNSCoreCompetenciesBroch.pdf Ratcliff, J. D. (2007). Home health admission and care of a pediatric ventilator-dependent client. Home Healthcare Nurse, 25(1), 35-40. Robertson, J. F. (2004). Does advanced community/public health nursing practice have a future? Public Health Nursing, 21(5), 495-500. Robertson, J. F., & Baldwin, K. B. (2007). Advanced practice role characteristics of the community/public health nurse specialist. Clinical Nurse Specialist, 21(5), 250-254. Ulch, P. A. O., & Schmidt, M. M. (2013). Clinical nurse specialist as community-based nurse case manager: Integral to achieving the triple aim of healthcare. Nurse Leader, 11(3), 32-35. Retrieved from http://www.nurseleader.com/article/ S1541-4612%2813%2900075-X/abstract
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