Presentation to Executive Leadership
Introduction: Major of Study
Master’s of Science in Nursing Generalist (MSN)
Analyze, Design, Implement, and Evaluate Nursing Care
Simplify the Complexity of Transitions in Care
Post-Acute /Long-Term Care Rehabilitation
Clinic – Preventive and Palliative Care
Acute – Reducing Readmission Rates for Exacerbation of Chronic Illness
MSN competencies allow for a full analysis of design, implementation, and evaluation of nursing care to diverse populations and cohorts of patients, in clinical and community-based systems, (American Association of Colleges of Nursing [AACN], 2011).
As a Director of Nursing within the long-term care continuum, having a MSN degree will allow for the integration of findings from across the sciences and humanities, and will facilitate continuous improvement of nursing care at the unit, clinic, home, and program level (AACN, 2011).
The DON who acquires their MSN provides for a strong background in healthcare leadership, assessment, pharmacology, and pathophysiology in preparation to understand how the systems and organizational sciences can blend to meet the healthcare needs of a diverse population (AACN, 2011). This blending of core components will provide the knowledge necessary for transitioning patients with Chronic Obstructive Pulmonary Disease (COPD) safely through their continuum of healthcare needs, within the micro-, meso-, and macrosystems of healthcare.
Introduction: Chronic Disease
Shortness of Breath
Expiratory Exertional Effort – Force or Time
Exposure to Risk Factors for the Disease
COPD is characterized by exertional effort, force or time, needed during the expiratory phase of the respiratory cycle, with the central symptoms being dyspnea, exercise intolerance, shortness of breath, chronic cough or sputum production, and/or exposure to risk factors for the disease, with the central sign being wheezing (Global Initiative for Chronic Obstructive Lung Disease [GOLD], 2018; McCance, & Huether, 2014).
Pathophysiology of COPD
Insult to Respiratory System
WBC Enter Bronchial Wall
Enlarged Mucous Glands & Goblet Cells
Inability to Clear Airway
The pathophysiology of COPD involves the inspired agent resulting in airway inflammation, white blood cells enter the bronchial wall, leading to edema and enlarged mucous glands and goblet cells, which in turn impairs ciliary function, which results in the body being unable to clear the lungs of debris (McCance, & Huether, 2014).
Primary: Tobacco Use
Abnormal Lung Development
The primary risk factor for COPD is tobacco use, with other risk factors including indoor air pollution, such as biomass fuel used for indoor cooking and heating, air pollution, genetic factors, abnormal lung development, and respiratory infections (GOLD, 2018; McCance, & Huether, 2014).
What happens with pulmonary insults?
Reduced Tidal Volume
Insults to the respiratory system results in an increased risk for respiratory infection, leading to further respiratory injury, resulting in COPD exacerbations of worsening dyspnea, productive cough, and air trapping; leading to reduced tidal volume, hypoventilation, and hypercapnia (McCance, & Huether, 2014, p. 1266-1267).
As lung function worsens, all other organs in the body are impacted.
Pulmonary Function Tests
Spirometry is most reproducible
Mild, Moderate, Severe, Very Severe
Blood Gas Analysis
(GOLD, 2018; McCance, & Huether, 2014)
Diagnosis is based on symptoms, physical examination, chest x-ray, pulmonary function tests, and blood gas analyses (GOLD, 2018; McCance, & Huether, 2014). GOLD (2018) notes that spirometry is the most reproducible and objective airflow measurement when diagnosing COPD. Airflow limitation severity is classified as mild, moderate, severe, and very severe (GOLD, 2018).
Prevention is key
Pathologic Changes are Irreversible
Halts Disease Progression
Immunizations Reduce Risk
(GOLD, 2018; McCance, & Huether, 2014)
Prevention of chronic bronchitis is the best treatment because pathologic changes are not reversible. However, if a person quits smoking tobacco, disease progression can be halted (GOLD, 2018; McCance, & Huether, 2014). Immunizations, such as influenza and pneumococcal, can reduce the risk of serious infection (GOLD, 2018).
Improve Exercise Intolerance
Risk for Exacerbation
Pharmacological therapy can improve COPD symptoms and exercise intolerance, and reduce exacerbations; however, treatment will be dependent on the individual’s symptom severity, risk for exacerbation, medication side-effects, comorbidities, pharmacological availability and cost, patient response to the agent, their preference, and ability to use the device (GOLD, 2018).
Inhaled & Oral Corticosteroids
Pharmacological agents include bronchodilators, Beta2-agonists – short and long acting, antimuscarinic agents – short and long acting, Methylxanthines, combination bronchodilator agents – short and long acting, anti-inflammatory agents, inhaled and oral corticosteroids, and oxygen (GOLD, 2018).
May incorporate pharmacological agents in some situations.
End of Life Care
Individualized to the patient and their family.
COPD: Typical Visit
Less than 20 Days
Discharge Goals are Individualized
The typical visit for someone entering the post-acute care setting is less than twenty days in length. The discharge goal and treatment options will be individualized to the patient. They will complete the admission process with Social Services, and the admission nurse, developing a baseline care plan.
COPD: Typical Visit
Baseline Care Plan
Language & Manner Understood by Patient & Family
The admission nurse will interview the patient and their representative, if not completed ahead of time, to determine their goals and preferences for care, such as code status, advance directives, living will, bathing and dining rituals, sleep patterns, spiritual needs, activities and hobbies, education level, occupation(s), level of assistance desired for activities of daily living, special equipment or treatments, desired discharge location and the ADL ability level needed for successful discharge. The patient and their representative will sign and date the baseline care plan, to include medication reconciliation, which will be produced in a language and manner they are able to understand.
COPD: Typical Visit
Meet & Greet
Introduction to Primary Staff
Physician Visits Every 30 Days, for first 90 days, every 60 days thereafter, and as needed
ARNP may complete every-other Physician required visit in SNF.
They will receive a visit from dietary services and the activity department, to learn likes, dislikes, and interests.
They will be introduced to their primary staff, to include: nursing assistant, housekeeper, unit aide, activity aide, nurse, and nursing supervisor. If therapy is ordered, evaluation and treatment will likely begin on day of admission. Their attending Physician or ARNP will make rounds every 30 days for the first 90 days, and every 60 days thereafter.
COPD: Typical Visit
Begins on Day One
Comprehensive Care Plan
Updated Summary from Baseline
Rehabilitation to Meet Goals
Internal & External Service Coordination
Transitions Between Levels of Care
Discharge planning also begins on day one. The comprehensive care plan will be completed within the first few weeks, within the time allowed as per state and federal regulations, and an updated summary will be provided to the patient and their representative if there are changes, also in a language and manner they are able to understand. The patient will receive restorative and/or rehabilitative services to meet their discharge goals, as well as medication and treatment assessment and teaching for adherence. Providers, social services, pharmacy, resident accounts, billers, therapists, dietary, activities, environmental service, special vendors (i.e., oxygen delivery, private or managed insurance companies, home health services) and nursing will coordinate internal and external services to ensure smooth transitions between healthcare providers, as the patient moves through the long-term care continuum and back to their prior or new setting.
Key Leadership Positions
County Commissioners – Operational Rules
Delegation Members – Financial Resources
Administrator – Vision & Mission
Department Heads – Supports Vision & Mission
Resident Council President – Guides Delivery of Services
Front-line Managers – Organize workflow
Natural Leaders – Optimize workflow, Feedback
Lead Nursing Assistants
Leadership positions within the long-term care continuum include those in formal and informal positions of authority. Formal leadership positions include the county commissioners and delegation members, the administrator, and the organization’s department heads, and resident council president. Informal positions of authority include front-line managers, and the natural leaders within a peer work group may include a nursing assistant who is passionate about a new or emerging topic, or a housekeeper who had a personal goal for keeping high-touch areas within the patient environment cleaned and disinfected hourly and is recruiting people to help her.
The macrosystem of the long-term care facility includes the county commissioners, the county delegation, and the nursing home administrator; the mesosystem includes the department heads and their interdepartmental staff (Linkosky, 2014). How these systems relate are knowing their functions, so as to leverage them to meet stakeholder expectations for improving quality, safety, and cost of care. The county commissioners determine the county rules for operational direction and setting of budgetary goals, the delegation oversee funding, and the administrator enforces policy and leads the safety and quality initiatives facility wide. The mesosystem supports the vision and mission of the macrosystem in the delivery of care.
For example, the county commissioners may instruct the administrator to seek additional revenue. The administrator seeks a Nurse Practitioner (NP) to hire, and will be billing Medicare for services rendered to patients within the long-term care facility. The DON and front-line managers formulate a plan to best organize the workflow to maximize the NP’s time, and to best meet the needs of the patients, optimizing the care delivery system.
Leadership Style Effectiveness
Anticipate Barriers to Goal Attainment
Coping & Positive Reinforcement
Gives All Team Members Voice in Workflow
(Cummings, Midodzi, Wong, & Estabrooks, 2010)
Leadership styles considered effective in reducing 30-day patient mortality in healthcare settings, in relationship to the management of COPD, include resonant leadership styles, such as visionary, coaching, affiliative, and democratic (Cummings, Midodzi, Wong, & Estabrooks, 2010). Using visionary leadership will help the patient to anticipate barriers in their treatment course and help them to plan for what they will need when returning to the community. With a coaching leadership style, the natural leaders at the bedside can facilitate independence in the patient, making their rehabilitation timelier. Understanding how to approach a difficult situation and avoiding negative coping through positive reinforcement will improve relationships and foster teamwork. Use of a democratic leadership style in the care environment can be time consuming, however, it allows for all team members to have a voice in the workflow, improving communication so that each team member can vocalize concerns and ideas for meeting the patients’ goals.
Oxygen Reserves for ADLs
Primary Care Access
In the post-acute/long-term care setting, barriers encountered by patients when managing their chronic disease include lack of transportation, lack of technological resources, lack of oxygen reserves for meeting selfcare needs/goals, and lack of a primary care provider in the community.
Patients with COPD will require the special skill sets of an MSN to improve the quality of care received, and to reduce the healthcare cost-burden of COPD management. Through implementation of advanced clinical reasoning for challenging clinical presentations, the MSN is able to incorporate the concerns of the patient, their family, significant others, and community into the strategy and dissemination of patient care (AACN, 2011).
Creating interprofessional partnerships and working with community resources, allows the MSN to transition the patient safely back to their primary or desired environment.
Obstructive Sleep Apnea
Gastroesophageal Reflux Disease (GERD)
Comorbidities place a patient at higher risk of morbidity and mortality (GOLD, 2018). Additionally, comorbidities reduce the patient’s ability for self-management of their personal health. Complications or symptoms may duplicate between diseases. For example, a person having COPD and Heart Failure may be short of breath, and less likely to realize they are in fluid overload and not in a COPD exacerbation. Assimilating an interdisciplinary team, within the setting of the patient having COPD, will allow for collaboration, timely, and correct care (GOLD, 2018).
Telemedicine may address:
Access to Primary Care
Note research is promising, however, level of evidence is poor
Further Research Needed
Telemedicine has the potential to impact both transportation and access to care (limited providers) barriers (Barken, Thygeses, & Soderhamn, 2017). However, this would depend on the state (licensing and authority) and organizational boundaries regarding the advanced nurses’ availability, as well as the infrastructure in the patients’ location to support electronic communication, as the ability to video conference was demonstrated to facilitate improved care more efficiently and confidently, when compared to teleconferencing (Barken et al., 2017). However, the level of evidence to support telemedicine’s effectiveness is poor, with further research needed in this area (Roche, 2017).
Telemedicine in Conjunction with Home Health Services
Smoking Cessation Monitoring & Support
Vaccination in the community/primary care
If too ill during SNF visit
Pulmonary Rehabilitation Monitoring & Treatment
Telemedicine would depend on the state (licensing and authority) and organizational boundaries regarding the advanced nurses’ availability, as well as the infrastructure in the patients’ location to support electronic communication, as the ability to video conference was demonstrated to facilitate improved care more efficiently and confidently, when compared to teleconferencing (Barken et al., 2017).
In conjunction with Home Health Services, there will be a safety net should the telehealth system fail. What are areas of promise or concern that you have identified in the use of telemedicine?
Quality of Life
Energy Conserving Techniques
(National Heart, Lung, and Blood Institute [NHI], n.d.)
When considering which solution would be the most effective for the COPD patient in the long-term care setting, the focused need would be to improve services surrounding pulmonary rehabilitation, due to the complexity of the patient’s disease process, likelihood of comorbidities, and it having the highest level of evidence of all available therapeutic options to manage COPD symptoms. The long-term care organization has a smoke-free policy, and the patient is automatically provided smoking cessation interventions, based on their individual needs, excluding e-cigarettes. Vaccinations are also part of a routine protocol, which is followed closely by the Infection Preventionist. The health-promotion activity I propose we focus on, within the pulmonary rehabilitation complex, is nutritional counseling. Nutritional counseling will promote muscle strength and overall quality of life in the malnourished patient, and will improve fatigue symptoms (Roche, 2017).
Relationships, Roles, Leadership Theory
Commissioners & Delegation Members with Health Information Technology Companies
The patient with the interdisciplinary team specializing in COPD
Pulmonary Rehabilitation Focus
Nutrition Component Initial Focus
Director of Nursing, MSN, Therapy, and Dietitian with the front-line staff and patient with COPD
Weekly team huddles
Exchange of information
Revision of patients’ goals
With the executive leadership team facilitating the improvements needed in community electronic infrastructure and resource allocation, implementation of the evidence-based research on Pulmonary Rehabilitation presented here, will demonstrate the greatest benefit to our stakeholders.
Additionally, it is something that all team members can participate in to support the patient in meeting their goals. Taking a team approach to supporting the resident in their nutritional goals will require weekly team huddles, with the patient at the center and directing the team, to allow for exchange of information and provision of education, resource allocation, or revision of goals.
This change will require the Director of Nursing to use a transformational leadership style to motivate team cohesion.
Reduce Hospital Readmissions
Improve Quality of Life in the COPD patient
Promote Staff Satisfaction
Facilitate Improved Transitions of Care
Improve Access to Healthcare
Clients will be elder adults who may not easily be persuaded to the benefits of a nutritional diet, and the idea of pulmonary rehabilitation will be a new concept for this team (Porter-O’Grady, & Malloch, 2018). Further consideration will be needed when considering the best way to present this concept to the front-line staff and patient. Thoughts and ideas from the audience are encouraged. Invite audience to share their stories around this topic.
Pulmonary Rehabilitation Program
Energy Conservation Techniques
Differential Diagnoses for COPD with Comorbidities
Disease Management – Clinician
Symptom Education & Reporting Guidelines – Patient
Knowledge and strategies to approach all areas of patient care and support in those living with COPD is important. The greater awareness of the presenting baseline symptoms will allow for sooner intervention in the face of an exacerbation (GOLD, 2018). Understanding the duplicative symptoms in a patient with COPD and comorbidities will facilitate greater depth in nursing assessment, more timely treatment/intervention, and improved patient quality of life.
Promotes muscle strength
Quality of Life
Improves Symptom Fatigue
If malnourished, reduced energy during respiration, due to high calorie needs
Maintain a Healthy Weight
Note: Smoking Cessation Halts COPD Progression
(GOLD, 2018; Roche, 2017; USDA|DHHS, 2015)
Nutritional Component Focus
Additional Funding for Dietitian & staff for team huddles
Human Resource Allocation & Learning Materials
Patient Teaching – Nursing, Dietary, Therapy
Patient Monitoring – Nursing, Provider, Therapy, Dietitian, Staff
Oxygen during meals as needed
Funding for Staff Education
Funding may be absorbed in this year’s budget excess. However, additional education funding for staff training should be dedicated to COPD and other chronic disease management education/training.
Summary: COPD Management
Patient-Centered Interdisciplinary Approach
Human & Financial Resources
Educational Resources – Staff & Patient
Resonant Leadership Styles
Visionary, Coaching, Affiliative, Democratic
Halts Progression of COPD
Pulmonary Rehabilitation Program Implementation
Beginning with Nutritional Focus
Effectiveness & Results Communication
Balanced Score Card
Weekly Team Huddles
Clinical status – Electronic Health Record Data
Patient/Staff Satisfaction Rating
QAPI – Director of Nursing, MSN
Reports outcomes for Department
When considering how recommendations will be measured to ensure they are effective for this COPD patient in the long-term care setting, a balanced scorecard model, as described by Nelson, Batalden, Godfrey, & Lazar (2011), will be used. During the weekly team huddle, the patient’s clinical status will be reviewed, using a facility generated standardized data collection form, summarizing the patient’s clinical status (comorbidities, vital signs, COPD symptom summary, meal percentage/caloric intake/protein intake/fluid intake), functional health status (ADL score), patient satisfaction rating, and number of Medicare A, B, Medicaid, or private pay days used during the pulmonary rehabilitation program in comparison to how many are remaining or anticipated discharge date. The Director of Nursing will take lead when reporting out these measures monthly to the Quality Assurance Process Improvement (QAPI) committee for further collaboration and monitoring of the program’s sustainability over time, and then provide follow-up feedback to the frontline staff during team huddles, incorporating a Plan Do Study Act (PDSA) process for continuous quality improvement (Nelson et al., 2011).
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