NP Care Model Drastically Lowers Heart Failure Readmissions

After a new care model positively affected outcomes related to HF patients, Holy Name Medical Center in New Jersey expanded the use of advanced practice nurses inside and outside the medical center.

If you were given carte blanche to create a nursing care model, what would it look like?

Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name Medical Center, in Teaneck, NJ, had to answer that question when the organization 's CEO handed  her the opportunity a few years ago.

She easily could have forged ahead alone, but instead Kutzleb sought the input of others to develop the model.

"I don 't really like to do anything alone, " she told me. "My leadership style is one that enhances others to grow, so I designed a subcommittee of nurse practitioners and clinical nurse specialists in order to come up with a model that would be able to be implemented in the organization. "

The group 's brainstorming sessions led to the creation of The NP Care Model, a patient-centered, collaborative-care approach intended to decrease readmissions and costs of care, and improve patient outcomes. The model 's details and outcomes were recently published in Nursing Economic$ .

"The model became the patient-centered model because the whole point is, if we 're meeting healthcare challenges, we need a collaborative team, " she says, "which means we 're not taking the place of anything. The model is not taking the place of anything. It 's going to enhance that which already being delivered. "

And enhance care it has.

A Win-Win Scenario
Evidence shows that APNs provide equal or better outcomes when compared to physicians, yet there is often still resistance to allowing APNs to function at the top of their licenses. 

In 2013, the New England Journal of Medicine published a study that reported "the Council of Medical Specialty Societies and the American Academy of Family Physicians strongly opposed broadening the scope of practice of nurse practitioners. "

But as Kutzleb points out, one provider doesn 't have to trump another.

"I don 't look at my place as a doctorally prepared nurse practitioner as taking a physician 's place, " she explains. "I look at it as a partnership. In a partnership, if I bring my best to the table, and the physician brings his best to the table, ultimately the patient 's going to win. "

As the results of the model show, when healthcare disciplines work collaboratively and APNs are given responsibilities that allow them use their administrative and clinical expertise, there can be big payoffs for patients, physicians, and the organization.

"The nurse practitioner is the conduit throughout the disciplines in order to make the patient experience and outcomes the very best, " Kutzleb says.

The program, which originally focused on heart failure patients, was implemented in January 2012.

Over a 12-month period, 30-day readmission rates dropped to 8% from 26%. Healthcare costs for the group of 312 patients receiving care via the NP Care Model was $311, 818 during 30-days after discharge. Prior to the model 's implementation, cost of care for this patient population during the 30-days post-discharge was $1,019,405.

Spreading Success
Together with the multidisciplinary team, the NP identified HF patients to be admitted to the program.
"We looked at those that we could catch early in the disease, " Kutzleb says. "By having patient engagement, they 're going to learn how to self-manage, and they 're going to have a better longevity with a chronic disease. "

The NP then met the patient and family, introduced herself and her role, and provided basic patient education in the hospital. They made post-discharge follow-up appointments with the patient for more intensive education sessions, as well as confirming the patient had follow-up appointments with the necessary physicians.

The NP worked with the physician on the care plan, made sure all diagnostic tests and reports were completed, medications were stable, and that the discharge plan was put into action.

After the patient was discharged, the NP connected with the patient by phone within 24 to 48 hours.

During the first NP follow-up visit, the patient received a full physical assessment and a full educational session with along with a family member or support person. The NP reviewed diet, daily weights, and set the patients up with a medication management tool that allows the NP to optimally schedule the patient 's medications. 

"By planning the medications throughout the day, they didn 't take all the medications all at once and then felt too tired to do anything else, " Kutzleb says. "It became a routine and then became inherent in their daily schedule. We gave them a printout and we were able to update that printout at any given time. It was successful, we had a tremendous drop in recidivism. "

The drop in recidivism went beyond the initial 30-day discharge period. The 60-day and 90-day readmission rates for the group receiving care through the model were 4% and 3% compared to 27% and 29% in a group receiving typical care.

Because of these significant results, advanced practice providers are being added to more of the medical center 's service lines including cardiology, chronic care management, oncology, and genetics.

The model 's success also helped Kutzleb make the case to deliver APRN provided care beyond the hospital walls.

"I was successful in writing a business plan and got approval from the physician oversight committee and opened the first fully run nurse practitioner primary care practice in Bergen county, " Kutzleb says.

With the old fee-for-service model transitioning to one focused on value-based care, Kutzleb says healthcare delivery will need to evolve as well.

"Healthcare is changing and for all its pluses and minuses, it needs to change. It wasn 't really ever meeting the needs of the patient. "