Coordination of Care: Strategies, Lessons, & Implications Danette Y. Wall, ACRN BSN, Herbert H. Lehman College, 1996 MSN, MBA, HCM, University of Phoenix, 2007 Carlow University Submitted to the Faculty of the Graduate School of Carlow University in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice December 6, 2011 Approval Page Carlow University IRB Approval Date: April 18, 2011 Location of Scholarly Inquiry Implementation: Veterans Health Administration IRB Approval Date: May 25, 2011-None Required Committee Chair Name: Kathleen M. Brown, DNP, RN Redacted Date: 12/10/2011 Interim Dean for the Graduate School: Robert Reed, PsyD Redacted Date: 12/10/2011 Committee Member Name: Shelley Waters, DNP, RN Redacted Date: 12/10/2011 Committee Member Name: Christine Elnitsky, PhD, RN Redacted Date: 12/10/2011 This page intentionally left blank This work is dedicated to the memory of my mother, Rose B. Wall, who always called me crazy for pursing this self-promise yet supported my efforts in every way. Standing like a rock and epitomizing strength; it is her legacy of resilience and perseverance that benchmark my life. Ma, we did it! “Me- that, which we know as a Rose, by any other name, will smell just as sweet” -Rose B. Wall 3/15/1974 Acknowledgements It is through my Lord and Savior Jesus Christ that all things are possible. For without him where would I be? This project culminates a long personal endeavor, nursing and educational journey. Along the way, I have encountered many great wise people, to include patients and colleagues, who have contributed to the success of this work in one way or another. I thank you. Specifically concerning this work, I would like to extend a sincere thank you, full of admiration, to my scholarly project committee. It has been an honor to work with you and I greatly appreciate your personal support especially during the tough times. A special thank you is due to Dr. Kathleen M. Brown, chair of the DNP committee. Through adversity, she maintained the ability to be supportive and caring. Your guidance throughout the entire experience made a difference. Also, I appreciate the time and interest of Dr. Shelley Waters, and Dr. Christine Elnitsky, whose questions and suggestions improved my work, and allowed me to grow as a scholar. Thank you to the DNP staff and faculty of Carlow University for accepting the challenge of not only starting a Doctor of Nursing Practice program, but achieving full accreditation. Your efforts created a supportive environment in which I was able to flourish, even from a distance. Lastly, yet most important of all, I have succeeded with the love and support of my family and friends. It was the affection and cheerleading from my daughter, Maya A. Rivera (No more ignore!) and my first born, Samuel L. Burwell Jr., whose birth was the driving force behind much of my success (Thanks for keeping mommy going!). I am forever grateful! ii Table of Contents Acknowledgements i Table of Contents ii List of Tables iii List of Figures iv List of Appendices v Abstract vi Chapter 1 Introduction 1 Background knowledge 1 Purpose 6 Project questions 8 Theoretical framework 9 Terminology/Definitions 16 Chapter 2 Review of the Literature 21 Introduction 21 Critique and synthesis of previous research 22 Rational for project 37 Chapter 3 Methods 41 Design 41 Population 41 Procedures 44 Instruments 46 Data analysis plan 53 Chapter 4 Results 54 Analysis of data 54 Summary of findings 84 Chapter 5 Discussion and conclusions 86 Discussion of findings 87 Limitations 103 Implications 105 Recommendations 108 References 114 Appendices 143 iii List of Tables Table 1 Overview of Data Collection Variables 52 Table 2 Care Coordinator Response Matrix 59 Table 3 Care Coordinator Demographics 61 Table 4 Care Coordinator Nursing Certifications 68 Table 5 Facility Complexity Response Matrix 69 Table 6 Educational Differences ANOVA 70 Table 7 Tools and Resources Results 72 Table 8 PES-NWI Results 74 Table 9 RCI Results 75 Table 10 Results Multiple Regression Analysis 76 Table 11 VHA and Project Results PES-NWI Comparison 97 iv List of Figures Figure 1 Conceptual SPO Framework 10 Figure 2 Conceptual Care Coordinator Hierarchy 71 v List of Appendices Appendix A Explanatory Email-Invitation to Participate 143 Appendix B Survey Email Reminders 144 Appendix C IRB Approvals-Carlow University 149 Appendix D IRB Approval-Orlando VHA 150 Appendix E PES-NWI Instrument 151 Appendix F RCI Instrument 161 Appendix G Demographic Data Collection Tool 157 Appendix H Permission to Use PES-NWI 160 Appendix I Permission to Use RCI 161 Appendix J Permission to Use Ingrid Duva‟s Dissertation 162 Appendix K Permission to Use Survey Monkey 163 vi Abstract Background: Care Coordination was identified as a fundamental process that can decrease care fragmentation. IOM and ANA identified Registered Nurses as capable of spearheading care coordination initiatives that will close the gap. It is well established that professional nurse environments positively affects nurse and patient outcomes, or conversely is a barrier when not present. A professional practice environment serves to facilitate care coordination (Duva, 2010). Expanding this work, using Donebedian‟s SPO Framework, this quality improvement project examined the relationship between the care coordinators work environment and the work processes of care coordination. Methods: A descriptive correlational design was used to survey 329 RNs from Veterans Health Administration Geriatric and Extended Care Line using Lake„s PES-NWI scale and Gittell„s RCI instrument. Analyses included descriptive statistics, correlations, and multiple regression analysis (Stepwise Method). Findings: Moderately positive significant correlations were found between the PES-NWI and RCI activities (r = .30, p< .001). Nurse participation in hospital affairs, staffing and resources adequacy, and Collegial Nurse-Physician relationship were significant predictors on overall perceptions of RCI, 24.8% of variance R2.248; F (3,110) = 12.11, p<0.001. Discussion/Implications: Findings support the linkage between the RN, the practice environment, and activities of care coordination. Integrated service delivery systems require a RN workforce that is ready, trained, functioning at their highest level of performance, and available to meet the current and future needs of health care delivery. Findings provide an actionable profile of the RN Care Coordinator, their practice environment, and strategies to improve both. Future study is required. This page intentionally left blank 1 CARE COORDINATION: STRATEGIES, LESSONS, & IMP Chapter 1- Introduction Background Knowledge Across industrialized nations, chronically ill patients account for a disproportionate share of national health spending, placing them at the center of initiatives to improve health system performance (Schoen, Osborn, How, Doty, & Peugh, 2009; CDC, 2009; Teiman et al., 2007; Hofmarcher, Howard, & Oxley, 2007). By 2020, the number of Americans with chronic illnesses is expected to increase from 125 million to 157 million, and those with multiple chronic illnesses are expected to increase from 60 to 80 million (CDC, 2009). Both national and international communities are making significant advances in the treatment of chronic conditions and the expansion of supportive services to maintain the independence of people with functional limitations. Despite these advances, navigating and accessing services has become more complex. Concerns remain over how to best serve people with chronic conditions continues to be on the agenda of practitioners, policymakers, healthcare organizations, and insurers. Stakeholders aim to make sense of dwindling budgets, ever-expanding deficits, and diminishing resources while increasing access to care, maintaining quality, safety, and ethical practices. Quality affordable healthcare has become a global concern (Lighter, 2011). This is also true within the Veterans Health Administration (VHA). VHA is the largest integrated national delivery system of care within the United States that provides comprehensive healthcare for the nation‟s veterans and active duty military (VHA, 2010; Sutto, Knoell, Zucker, Finstuen, & Mangelsdorff, 2008; Francis & Perlin, 2006). This integrated network is comprised of medical centers, nursing homes, clinics, and other non-institutional care facilities. Review of 2 the Network‟s population noted 3% of veterans served were consuming 41% of the total resources. Identification of these veterans found them to be either medically complex, chronically ill elderly, or younger veterans with psychiatric illnesses (VHA, 2009). Besides being the largest integrated health care organization, research looking at processes of care consistently demonstrated that the VA performed better than non-VA comparison groups (Trivedi, 2011). Care Coordination Care Coordination has been identified as a fundamental process that can decrease care fragmentation, improve patient outcomes, and bridge health care teams (Johnson & Burik, 2010; Mollica & Gillespie, 2003). Care coordination interventions have the potential to improve both efficiency and quality in health care (Wooten, Gramotnev, & Hailey, 2009; Englelhardt et al., 2006). It is assumed that when care coordination is working, people are supported in all areas across the continuum of care (Palsbo, Mastal, & O‟Donnell, 2006). Key problems have been identified at the interface level of care coordination, especially during transitions from one provider