Primary care bundle aims to reduce ED, hospital readmissions

Health 360 is designed to be applied by an interprofessional collaborative care team and facilitated by nurse practitioners.

NEW ORLEANS — A bundled care approach called Health 360 designed by a group of nurse practitioners at the University of Arizona College of Nursing is aiming to improve the quality of care for complex patients at high risk for readmission to the ED or hospital. 

“The bundle is designed to be applied by an interprofessional collaborative care team and facilitated by nurse practitioners,” Paula Christianson-Silva, DNP, RN, ANP-BC, explained during a poster session at the American Association of Nurse Practitioners 2015 meeting.

The care team consisted of three nurse practitioners, a full time registered nurse, a full time community health worker, three physicians and a pharmacist that meet once a week to discuss the patients and ensure a higher level of access to care to prevent the patients from returning to the hospital.

Christianson-Silva, along with colleague Audrey Russell-Kibble, DNP, RN, FNP-C, and principle investigator Sally Reel, PhD, RN, FNP, BC, FAANP, FAAN, and the inter-professional collaborative care team developed the care bundle to help providers remember certain care procedures using the pneumonic “AEI0OU,” which stands for the following: 

  • Access to team-based care coordination — ensuring all patients and their family members have contact information for all members of the inter professional team, and that weekly patient  Advancing Care Together team report is completed
  • Essential basic needs assessment — completing a comprehensive health assessment
  • Identification and rectification of gaps in care — documenting significant diagnoses that have fallen off the current problem list and history of abnormal lab results and reviewing at regular intervals
  • 0 — zero days without essential medications — ensuring timely and ongoing medication refill management for all medications prescribed for ongoing problems, including interval reviews and medication reconciliation after ED or hospital discharge
  • Occasions for assess and engaging family or close others in supporting patient care — making sure all names and telephone numbers for all caregivers are listed in the care coordination note in the EHR
  • Utilization of available resources, services, and devices — performing referrals to specialists and services to support care, including counseling, home health, safety and fall risk evaluations, nutrition consults, medication reconciliation and management, and durable medical equipment

“Applying the bundle helps assure all team members adhere to our core values for care fundamentals,” Russell-Kibble said. 

So far the program has enlisted about 70 patients, some of whom have been transitioned out and 50 of whom are active in the program at any given time, and preliminary data are promising. Comparing data from 6 months prior to program implementation, to six months after and the observed initial decreases in readmission rates is quite significant, according to Christianson-Silva. 

“It's often difficult to quantify how much you've saved from prevention, but we've certainly seen significant decreases in the number of hospital readmissions and emergency department visits,” she added. 

The next phase is determining how to incorporate Health 360 in everyday practice, Reel said. They hope to do this by linking the practices to patient outcome measures and integrating the bundle into a checklist.  The project is supported by U.S. Department of Health and Human Services grant #UD7HP25053.

Reference

  1. Russell-Kibble A et al. Poster Session. “Bunding Practices to Improve Care of Patients at High Risk for Hospital or ED Readmissions.” Presented at: AANP 2015. June 10-14; New Orleans, Louisiana. 
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