NURS-FPX9100 Topic Approval Form

LEARNER INSTRUCTIONS

WORKING PROJECT TITLE:

Implementing Evidenced Based Palliative Focused CHF Protocol for Advance

Practice Clinicians in Long Term Care

Primary Investigator: Dora Agyemang

Project Site: Optum- United Health Group

Sponsor: (Lora Crowe, PHD (senior clinical service manager) and Adrienne Peart APRN, NPC (Clinical Service Manager)

PROJECT DESCRIPTION:

The purpose of the project:

Advanced Practice Clinicians (APC) will implement the AHA guidelines for members with NYHA class IV heart failure in the long-term care.

PICOT:

In advanced practice clinicians in complex care management at Optum (P) implementation of CHF palliative care protocol (I) compared to No heart failure protocol (c) to measure APC compliance with CHF protocol for patients in long -term care (O) within 10 weeks(T)

Brief Summary:

GAP IN CARE

Optum Health is a subsidiary of the United Healthcare Group responsible for providing healthcare services to those who are insured by United healthcare insurance products. Therefore, the strategic priorities of Optum health reflect the corporate mission and core values that align with the broader United Health Group (UHG) vision of improving customer experience by making healthcare work better for everyone by helping people live healthy lives.  The strategic priorities of UGH-Optum health for 2021 includes expanding access to preventative care services to 85% of its customers by year 2030, shifting 55% of outpatient surgeries to a high-quality, cost-effective setting by year 2030 and closing 600 million gaps in care for customers by the 2025 (UHG, 2020). Undoubtedly providing affordable, quality, safe, and effective patient care set precedence and is the number one priority of UHG. Achieving high-quality outcomes, lower costs, and improved consumer and physician satisfaction, driven by our high-performing local care practices. UHG have the focus of efficient and profitability of the services provided by the organization, low-cost services is a priority

The problem at the practice site is the lack of use of an evidenced-based protocol for APCs to proactively manage members with CHF with reduced ejection fraction in long-term care. Even though some patients are managed by a cardiologist and have echocardiograms, they are not readily available to the APC at the skilled nursing facilities. However, the skilled nursing facilities become the patient’s medical home under the management of Optum APC. Therefore, the Optum APC can manage the polypharmacy and CHF regimen per AHA guideline. Ten patients with heart failure with reduced ejection fraction diagnoses were selected, reviewed, and compared with AHA guidelines. None of the charts audited had ARNI (angiotensin receptor-neprilysin inhibitor) known as Entresto is part of the AHA recommendation for management of heart failure with reduced ejection fraction. Four patients with African American (AA) heritage are not on Hydralazine and only one patient was one SGLT2i as indicated by the guideline(Heidenreich P, Bozkurt B, Aguilar D, et al. 2022). All ten charts reviewed had full code status indicating a lack of understanding of disease trajectory and recommendations (Mechler & Liantonio, 2019).

Primary Objective:

Streamline Advanced Practice Clinicians the use of palliative care protocols for CHF patients at Optum

Proposed Evidence-based Intervention

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PROJECT DESIGN AND METHODS

Project Design: The project is a quality improvement process that seeks to Implement palliative approach heart failure management protocol for APCs in senior community settings.

Model for Improvement: PDSA

Target Population Undergoing the Practice Change: The target population will be the Advanced Practice Clinicians in a senior community and long-term care setting.

Inclusion Criteria: All full-time and part-time nurse practitioners or physician assistants working at Optum senior complex care management program.

Exclusion Criteria: The project excludes physicians, pharmacists, RN’s and social workers. 

Estimated Project Length (weeks): The project will take ten weeks. The initial step is pre-work, including training and will last two weeks. The implementation will take six weeks. The final process will take two weeks for a total of 10 weeks.

OUTCOME MEASURES AND ANALYSIS

Primary Outcome Measure:

• Consistent and compliance use of evidence based palliative approach heart failure protocol

Data Analysis and Results Reporting

There will be weekly chart review of all charts at the long-term care facility for compliance with the NYHA class IV guidelines. There will be retraining for providers for those charts not in compliance with the guidelines through weekly briefings.

References

Heidenreich P, Bozkurt B, Aguilar D, et al. (2022). AHA/ACC/HFSA guideline for the

management of heart failure. Journal of the American College of Cardiology, 79(17) 263-421.https://doi.org/10.1016/j.jacc.2021.12.012

Mechler, K., & Liatonio, J. (2019). Palliative care approach to chronic diseases: End stages heart failure, chronic obstructive pulmonary disease, liver failure and renal failure. Primary Care. 46(3), 415-432. https://doi.org/10.1016/j.pop.2019.05.008

Riahi, S., & Khajehei, M. (2019). Palliative care: A systematic review of evidence-based interventions. Critical Care Nursing Quarterly, 42(3), 315-328. https://www.researchgate.net/publication/333375860_Palliative_Care_A_Systematic_Review_of_Evidence-Based_Interventions

Ryann, E., David, M., Sally, H., Nealon, M., Melissa, A., Jennifer, L., & Mark, M. (2021). Evidence-based practice and patient-centered care: Doing both well. Health Care Management Review, 46(3), 174-184. https://journals.lww.com/hcmrjournal/Fulltext/2021/07000/Evidence_based_practice_and_patient_centered_care_.2.aspx

Seow, H. & Bainbridge, D. (2018). The development of palliative care in the community: A

qualitative study of evolution of 15 teams. Palliative Medicine, 32(7),1255-1266. https://doi.org/10.1177/0269216318773912

The Centers for Medicare and Medicaid services (CMS) 2020.

http://www.cms.gov/Research-Statistics-Data-and-Systems