• Evidence-Based Approach for Identification of Malnutrition and Prevention of Skin Breakdown

      Bederak, Dmitry; Windemuth, Brenda (2021-05)
      Problem: Geriatric patients have an increased risk for skin breakdown due to advanced age, immobility, comorbidities, and poor nutrition. As malnutrition contributes to impaired skin integrity, patients may experience ulceration, infection, and pain. Administrators within a long-term care (LTC) facility expressed concerns about undetected malnutrition or the risk of malnutrition leading to skin breakdown. The incidence rate of skin breakdown in January of 2020 was 6.37%. Purpose: The purpose of this quality improvement (QI) project was to implement and evaluate use of the Mini Nutritional Assessment (MNA) for patient admissions/readmissions within a LTC setting, for early recognition of malnutrition and prompt intervention to prevent skin breakdown. Methods: Implementation relied on Lewin’s Change Theory, utilizing evidence to manifest and sustain change. Strategies/tactics included meetings with administrative and nursing staff to review current processes for patient admission and dietary evaluation, training nursing staff on use of the MNA, and implementation of an improved communication system for dietary referrals. The project was implemented at a 130-bed LTC facility and clinicians included 12 nurses, 2 providers, and 1 dietician. Inclusion criteria included all admissions/readmissions. Implementation data was collected at weekly intervals using electronic reports and chart audits. Protection of confidentiality/privacy included collection of anonymous data. Data was analyzed using run charts to evaluate trends and variation in MNA use. Results: Over 14-weeks of implementation, 38 patients were admitted/readmitted to the LTC facility. The MNA was completed for 32 (84.1%) of patients, and 18 (56.3%) of those patients were identified as being malnourished or at risk for malnutrition. Run chart analysis indicated no shifts, trends, astronomical data points or abnormal variation in runs. Prior to implementation of the practice change, the rate of compliance in utilizing the MNA increased from 0% at baseline to vary weekly between 40% and 100%, indicating initial adoption of the screening tool by nurses. Conclusions: The MNA provided an effective means for establishing nutritional status in order to prompt early nutritional intervention to prevent skin breakdown. The MNA has the potential to enhance prevention efforts, reduce costs associated with in-house acquired wounds, and minimize factors contributing to patient decline.
    • Implementing Medicare Annual Wellness Visits with a Health Risk Assessment in Primary Care

      Owens, Tiffany N.; Bundy, Elaine (2019-05)
      Background: Within the primary care setting, there is a deficiency of comprehensive, personalized treatment care plans that identify modifiable risk factors and endorse preventive care. The Medicare annual wellness visit presents an opportunity for patients aged 65 years and older to identify, plan, and optimally manage chronic health conditions and increase preventative care. The health risk assessment, which is part of the annual wellness visit, is intended to identify health behaviors and risk factors that can be discussed with the patient and utilized to collaboratively create a personalized prevention plan that aims to reduce risk factors and related diseases. Local Problem: In a small, single practitioner primary care office, there was a low performance of completion of annual wellness visits with the Medicare population and lack of a consistent method to assess health risks within this population. This practice serves a Medicare population of greater than 300 patients yet only billed a total of 39 annual wellness visits in 2017 and 15 in 2018. The purpose of this quality improvement Doctor of Nursing Practice project was to increase the number of Medicare annual wellness visits, which included the use of a Health risk assessment in a primary care practice, for Medicare patients aged 65 years and older with chronic health conditions. Interventions: The project was implemented over a 14 week period. Mail and telephonic outreach were conducted to all eligible Medicare patients. For beneficiaries with preexisting appointments, annual wellness visits were added to the appointments. Health risk assessments were mailed to the patient after the appointment was scheduled with instructions to complete prior and bring to the scheduled appointment. Health risk assessments were collected when the patient checked in for the scheduled appointment. Results: The percentage of annual wellness visits completed or not completed (among eligible patients) during the pre- intervention and post- intervention was determined by dividing the total number of eligible patients who completed their annual wellness visits by the total number of eligible patients. At the conclusion of the project, there was a 23.7%, or five- fold- increase in the annual wellness visits completed, which is statistically significant. Post- intervention chart audits revealed health risk assessments in 100% of the charts when an annual wellness visit was completed. Conclusions: Annual wellness visits can be integrated successfully in a busy outpatient primary care practice within the time allocated for office visits. Completion of annual wellness visits increased significantly over the project two month implementation timeframe. A tracking tool revealed a higher capture rate when annual wellness visits were scheduled with pre- arranged office visits. Patient and provider participation in the process increased referrals for preventative screenings and vaccinations. The annual wellness visit also has the opportunity to increase practice revenue gained from Medicare reimbursement and increased relative value units.
    • Screening for Polypharmacy in the Elderly Population

      Weir, Brett; Costa, Linda (2019-05)
      Background. The population of 65 years and older has increased exposure to polypharmacy, with data showing up to 42% taking five or more medications. Polypharmacy increases the frequency of potentially inappropriate medications prescribed which are associated with adverse drug events and higher healthcare costs. The Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria have demonstrated effectiveness in identifying potentially inappropriate medications and preventing adverse drug events. Local Problem. A large, academic medical center neurology practice site used a standard medication reconciliation for its patients over the age of 65. They did not have an enhanced medication screening process for that population. Interventions. The quality improvement project used the Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria to augment the medication reconciliation process on the general neurology inpatient service. The transtheoretical model was used to guide interventions based on the stages of change to produce this change in behavior towards enhanced medication screening. During the seven-week implementation, patients over age 65 admitted to the service were screened by providers using the tool’s criteria. A clinical pharmacist consultation was to be initiated for positive findings. Results. During the implementation, 29 of the 73 patients admitted to the service were eligible for screening. The providers completed nine screenings for an overall compliance of 31%, falling below the goal of 80%. Five (55%) of the patients screened positive, resulting in three consults to the clinical pharmacist for an overall consult compliance of 60%. Two of the positive screenings resulted in medication changes for the patients. Following the implementation, the providers evaluated the Screening Tool of Older Persons’ Prescriptions and Screening to Alert to Right Treatment criteria using the System Usability Scale with a final average score of 86.25 out of 100, indicating the process was highly usable. Conclusions. Despite the low compliance with screening, the presence of a potentially inappropriate medication in 55% of the patients screened suggests this population is at a high risk for polypharmacy exposure and enhanced medication reconciliation is warranted. A behavior change was not fully established among the physician team as they remained in the contemplative stage of change while the nurse practitioner on the team progressed to the action stage. The results from the System Usability Scale survey indicated the criteria were easy to use and are a viable option for sustained integration into the medication reconciliation process. The loss of the provider champion greatly impacted the ability of the project lead to achieve buy-in with the neurology team. The results of this project are limited based on the small sample size and a complete turnover of resident physicians during the implementation. A focus on achieving provider buy-in is necessary to achieve sustainability. Future work should be aimed at the development of an automated version of the criteria, integrating the process into established workflow, and the evaluation of the impact of medication screening on patient outcomes such as medication costs and adverse drug events.