CHAPTER 8
CARE COORDINATION FOR A PATIENT IN ACUTE CARE
In this chapter, we use the Care Coordination Clinical Reasoning (CCCR) systems model as described in Part I and explain how the model can be used to reason about an acute care case. The case presented in this chapter illustrates how an advanced practice nurse works with a patient who requires admission to an acute care unit after being seen in the emergency department because of new-onset confusion. The emergency department is the first point of access for the patient. The advanced practice nurse provides care coordination through the application and use of critical-, creative-, systems-, and complexity-thinking processes to manage patient problems with an interprofessional team to design appropriate interventions and establish patient-centered outcomes. Depending on the nature of need involved in the case, referrals to other specialty or primary care providers are determined (Haas, Swan, & Haynes, 2014).
The CCCR systems model framework begins with the patient story, which is derived from gathering data and evidence from an interview, history, physical examination, and the health record. The advanced practice nurse then develops a patient-centered plan of care using the Outcome-Present State-Test (OPT) model worksheets. In order to do this, one activates patient-centered systems-thinking skills for complex patient stories and consistently uses key questions to reflect on the specific sections of the model (Pesut, 2008), as well as the dimensions and elements of care coordination.
LEARNING OUTCOMES
After completing this chapter, the reader should be able to:
1. Explain the components of a care coordination framework that are needed to manage the problems, interventions, and outcomes of acute care patients managing health care issues
2. Describe the different thinking processes that support clinical reasoning skills and strategies for determining priorities and desired outcomes for the acute care patient
3. Define the cognitive and metacognitive self-regulatory processes that support individual provider critical reflection related to levels and perspectives associated with clinical reasoning for the acute care patient and care coordination
4. Describe how the communication and knowledge management between interprofessional health care team members are essential for care coordination to address acute care patient needs
5. Describe the critical meta-reflective processes that support team reflection and value-added impact related to levels and perspectives associated with the care coordination challenges and clinical reasoning required to navigate acute care patient care plans
THE PATIENT STORY
We begin with the history and story of an 87-year-old male, Tony Brown, who presents with new-onset confusion, right-side weakness, slurred speech, and altered mental status. All the symptoms resolved during transport to the emergency department prior to any interventions. Mr. Brown’s friend called 911 because he was confused and had difficulty using his right side. These symptoms lasted 45 minutes. On arrival to the emergency department, Mr. Brown had a CT scan of the head and was medicated with 325 mg of aspirin.
Mr. Brown reports a similar episode occurred in 2007, with a negative workup. In 2011, warfarin was changed to a novel anticoagulation agent because there was difficulty in managing the international normalized ratio (INR). The patient denied excessive alcohol intake on admission and had a negative CAGE questionnaire assessment (an acronym formed from the first letters of the most significant words used in the four questions in the questionnaire [Cut/Annoyed/Guilty/Eye-opener]). During his hospital stay he developed delirium tremens. It is noted that Mr. Brown has a poor support system and as no familial relationships. Mr. Brown also admits to poor medication compliance and often misses several doses of the anticoagulant per week.
His past medical history includes the comorbidities of transient ischemic attack, chronic atrial fibrillation, nonischemic cardiomyopathy, and hyperlipidemia. He drinks alcohol and is nonadherent with his medication regimen. Current medications include colchicine, dabigatran, hydrochlorothiazide, and pravastatin.
The physical examination reveals a height of 5’ 11”, weight of 95.39 kg, body mass index (BMI) of 29.4, blood pressure of 148/66 mmHg, heart rate of 87 beats per minute, temperature of 96.3oF, and a respiratory rate of 16 breaths per minute. His oxygen saturation was 100% on room air. Other laboratory values are as follows: EKG shows atrial fibrillation with left axis deviation and no ST- or T-wave elevations or depressions; CT scan of the head shows appropriate age-related atrophy without hemorrhage, mass effect, or edema.
PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS
Once the story is obtained from all possible sources, care planning and reasoning proceeds using the OPT clinical reasoning web worksheet (Figure 8.1), which helps determine relationships among issues and highlights potential keystone issues. The OPT clinical reasoning web offers a graphic representation of the functional relationships between and among diagnostic hypotheses derived from the analysis and synthesis regarding how each element of the story and issues relate to one another. This activates critical and creative thinking. The visual diagram that results illustrates dynamics among issues and a convergence helps to point out central issues that require nursing care. As one thinks about this case, and begins to spin and weave a clinical reasoning web, relationships are identified among nursing domains and diagnoses as they are jointly considered with medical conditions. The medical conditions in this case are history of chronic atrial fibrillation, nonischemic cardiomyopathy, harmful use of alcohol, encephalopathy, hyperlipidemia, essential hypertension, lack of physical exercise, self-damaging lifestyle, noncompliance with medication regimen, risk for falls, and a hypercoagulable state. Once the advanced practice nurse considers these diagnoses, the nursing care domains associated with them are identified. The complementary nursing diagnoses most impacted in this case are risk for ineffective relationships, risk for ineffective cerebral tissue perfusion, noncompliance, and risk-prone health behavior.
FIGURE 8.1 Outcome-Present State-Test clinical reasoning web worksheet.
ICD-10, International Classifications of Diseases, 10th edition; TIA, transient ischemic attack.
To spin and weave the web, the provider uses thinking processes to analyze and synthesize relationships among diagnostic hypotheses associated with a patient’s health status. The visual representation and mapping of these relationships supports the development of patient-centered systems thinking and connections between and among the medical and nursing diagnoses under consideration, given the patient story.
The steps to the creation of the OPT clinical reasoning web using the worksheet are as follows:
1. Place a general description of the patient in the respective middle circle—87-year-old male presents to the emergency department with new-onset confusion.
2. Place the major medical diagnoses in the respective middle circle—transient ischemic attack.
3. Place the major nursing diagnoses in the respective middle circle—risk for ineffective relationships, risk for ineffective cerebral tissue perfusion, noncompliance, and risk-prone health behavior.
4. Choose the nursing domains for which each medical and nursing diagnosis is appropriate—activity/rest, coping/stress tolerance, perception/cognition, nutrition, health promotion, self-perception, life principles, safety protection, and role relationships.
5. Generate all the International Classification of Diseases (ICD)-10 codes that are appropriate for the particular patient story that coincide with the nursing domains—transient ischemic attack (G45.9), chronic atrial fibrillation (I48.2), nonishcemic cardiomyopathy (I142.9), harmful use of alcohol (F10.10), encephalopathy (G93.4), hyperlipidemia (E78.5), essential hypertension (I10), lack of physical exercise (Z72.3), self-damaging lifestyle (Z72.89), noncompliance with medication regimen (Z91.14), at risk for falls (Z91.81), hypercoagulable state (D68.69), and risk for ineffective relationship (F93.8).
6. Once the nursing domains, diagnoses, and ICD-10 codes are identified, reflect on the total web worksheet and concurrently consider and explain how each of the issues is or is not related to the other issues. Draw lines of relationship to spin and weave the web connections or associations among the ICD-10 codes/diagnoses. As you draw the lines, think out loud, justify the reasons for the connections, and explain specifically how the diagnoses may or may not be connected or related.
7. After you have spent some time connecting the relationships, determine which domain/domains have the highest priority for care coordination and most efficiently and effectively represent the keystone nursing care needs of the patient by counting the arrows that connect the medical problems (ICD-10 codes). In this case, counting 15 lines (Table 8.2) that point to or from the nursing domain of activity/rest represents the priority, present-state keystone issues.
8. Look once again at the sets of relationships and determine the theme or keystone that summarizes the patient-in-context or the patient story—the problems related to transient ischemic attack from chronic atrial fibrillation and noncompliance with anticoagulation medications are the keystone issues for this case.
The OPT clinical reasoning web worksheet in Figure 8.1 shows a template with the patient health care situation, medical diagnoses, and nursing diagnoses at the center. Around the outer edges of the web are nursing domains with ICD-10 codes derived from history and physical assessment associated with the patient story. The directional arrows create the web effect and represent connections, explanations, and functional relationships between and among the diagnostic possibilities. As one can see, the domains and ICD-10 codes with more connections converging on one of the circles display the priority problem or keystones, in this case activity/rest. A keystone issue is one or more central supporting elements of the patient’s story that help focus and determine a root cause or center of gravity of the system dynamics and help guide reasoning and care coordination based on an analysis (breaking things down into discrete parts) and synthesis (putting the parts together in a greater whole) of diagnostic possibilities as represented in the web. A key question to ask here is: How does the clinical reasoning web reveal relationships between and among the identified diagnoses and to what degree do these relationships make practical clinical sense according to the evidence and patient story? Table 8.1 shows a summary of the connections highlighting the priority with the most connections.
After considering the full picture using the clinical reasoning web worksheet, the next step is to use an OPT clinical reasoning model worksheet to facilitate and structure the patient-centered systems thinking about the care coordination of the identified problems highlighted in Table 8.1. As the advanced practice nurse thinks about the patient, she or he will concurrently consider the frame, outcome state, and present state. Each aspect of the OPT clinical reasoning model contributes to the other. The OPT clinical reasoning model worksheet is a map of the structure designed to provide a representation and guide thinking processes about relationships between and among competing issues and problems. Some questions that guide the use of the OPT clinical reasoning model are shown in Table 8.2 (Pesut, 2008).
TABLE 8.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections
NURSING DOMAINS | MEDICAL DIAGNOSES (ICD-10 CODES) | WEB CONNECTIONS |
Activity/rest | Transient ischemic attack G45.9 Chronic atrial fibrillation I48.2 Nonischemic cardiomyopathy II42.9 | 15 |
Coping/stress tolerance | Harmful use of alcohol F10.10 | 13 |
Perception/cognition | Encephalopathy G93.4 | 6 |
Health promotion | Essential hypertension I10 Lack of physical exercise Z72.3 | 6 |
Self-perception | Self-damaging lifestyle Z72.89 | 6 |
Life principles | Noncompliance with medication regimen Z91.14 | 5 |
Safety/protection | At risk for falls Z91.81 Hypercoagulable state D68.69 | 5 |
Nutrition | Hyperlipidemia E78.5 | 4 |
Role relationships | Risk for ineffective relationship (nursing diagnosis) | 3 |
Source: World Health Organization (2015).
By writing each element on the worksheet, all the parts of the model become related to each other. As the health care provider moves from right to left, the model structures the plan of care. Critical thinking skills are used to consider the patient story and creative thinking is used to identify and reason about the keystone issues/themes/cues to determine the most significant evidence in the present state. Complexity thinking helps the provider to consider the outcomes desired and the gaps between the present and outcomes states. Once interventions and tests are decided, the plan of care transitions over to a care coordination model and team-centered systems thinking which considers patient preferences within the frame of the situation.
The patient-in-context story (Exhibit 8.1) is depicted on the far right-hand side of Figure 8.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics: 87-year-old male who lives alone without social support. He has diagnoses of chronic atrial fibrillation, nonischemic cardiomyopathy, harmful use of alcohol, encephalopathy, hyperlipidemia, essential hypertension, lack of physical exercise, self-damaging lifestyle, noncompliance with medication regimen, risk for falls, and hypercoagulable state. He currently has had a transient ischemic attack complicated by delirium tremens while in the hospital. His initial treatment was with an aspirin and his symptoms subsided during transport to the emergency department. He has essential hypertension, nonischemic cardiomyopathy, harmful consumption of alcohol, and noncompliance with his medication regimen. Because of the lack of social support, he has no resources to rely on for day-to-day care activities and medical-needs management. The acute care nurse practitioner will pull the acute care team together to promote his health and manage his chronic comorbidities while in the hospital. Significant laboratory data show no acute changes on the CT scan of the head or the EKG. A key point at this juncture is to review and reflect on the patient story for accuracy and thoroughness to proceed with care planning for care coordination.
TABLE 8.2 Questions That Guide the Use of the OPT Model
Patient-in-context | What is the patient story? |
Diagnostic cue/web logic | What diagnoses have you generated? What outcomes do you have in mind given the diagnoses? What evidence supports those diagnoses? How does a reasoning web reveal relationships among the identified problems (diagnoses)? What keystone issue(s) emerge? |
Framing | How are you framing the situation? |
Present state | How is the present state defined? |
Outcome state | What are the desired outcomes? What are the gaps or complementary pairs (~) of outcomes and present states? |
Test | What are the clinical indicators of the desired outcomes? On what scales will the desired outcomes be rated? How will you know when the desired outcomes are achieved? How are you defining your testing in this particular case? |
Decision making (interventions) | What clinical decisions or interventions help to achieve the outcomes? What specific intervention activities will you implement? Why are you considering these activities? |
Judgment | Given your testing, what is your clinical judgment? Based on your judgment, have you achieved the outcome or do you need to reframe the situation? How, specifically, will you take this experience and learning with you into the future as you reason about similar cases? |
OPT, Outcome-Present State-Test.
Adapted from Pesut (2008).
EXHIBIT 8.1 PATIENT-IN-CONTEXT STORY
Tony Brown is an 87-year-old male with new-onset confusion from a transient ischemic attack. Symptoms of confusion and right-sided weakness subsided during transport to the hospital. He developed delirium tremens while in the acute care unit. He admits to harmful alcohol intake and noncompliance with his medication regimen. He lives alone and has no support system.
Prescribed medications include dabigatran, hydrochlorothiazide, and pravastatin.
BP: 148/66 mmHg, O2 sat: 100%, temperature: 96.38oF, pulse: 87, respiration: 16, BMI: 29.4, CT of the head is negative, and EKG shows no significant changes
BMI, body mass index; BP, blood pressure, O2 sat: Oxygen saturation.
FIGURE 8.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.
AA, Alcoholics Anonymous; BMI, body mass index; DTs, delirium tremens; INR, international normalized ratio; PT, prothrombin time; TIA, transient ischemic attack.
Moving to the left of the figure, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 8.2). At the bottom of this box is placed the designated keystone issues or themes that fall under the most significant nursing domain—transient ischemic attack G45.9. Remember diagnostic cluster cue web logic is the use of inductive and deductive thinking skills. Some key questions to ask here are: What diagnoses were generated? Is there evidence to support those diagnoses? Is the keystone issue appropriate, given this patient story?
In the center and background of the worksheet are places to indicate the frame or theme that best represents the background issues regarding thinking about the patient story (Exhibit 8.3). The frame of this case is an 87-year-old male who presents to the emergency department with new-onset confusion, right-sided weakness, delirium tremens, medication adherence issues, and lack of a support system. This frame helps to organize the present state, outcome state, illustrates the gaps, and provides insights about what tests need to be considered to fill the gap. Decision making and reflection surround the framing as the advanced practice nurse thinks of many things simultaneously. Reflective thinking is used to monitor thinking and behavior. Key questions to ask here are: How am I framing the situation and does it agree with the patient’s view of the situation? Given my disciplinary perspectives, what are the results I want to create for this person?
EXHIBIT 8.2 DIAGNOSTIC CLUSTER CUE WEB LOGIC
1. Noncompliance with medication regimen Z91.14
2. At risk for falls Z91.81
3. Hypercoagulable state D68.69
4. Essential hypertension I10
5. Lack of physical exercise Z72.3
6. Hyperlipidemia E78.5
7. Harmful use of alcohol F10.10
8. Chronic atrial fibrillation I48.2
9. Nonischemic cardiomyopathy II42.9
10. Encephalopathy G93.40
11. Self-damaging lifestyle Z72.89
12. Risk for ineffective relationships
KEYSTONE ISSUE/THEME
Transient ischemic attach G45.9
EXHIBIT 8.3 FRAMING
An 87-year-old male presents to the emergency department with new-onset confusion, right-sided weakness, and delirium tremens; no support system; medication-adherence issues.
EXHIBIT 8.4 PRESENT STATE
1. Delirium tremens
2. Encephalopathy
3. Harmful use of alcohol
4. Poor support system
5. Medication-compliance issues
6. Lack of physical exercise
EXHIBIT 8.5 OUTCOME STATE
1. Stabilization of delirium tremens
2. Resolution of encephalopathy
3. Alcohol-use cessation
4. Community support programs and personal support system
5. Medication compliance
6. Cardiac rehabilitation
At the center of the sheet are spaces to place the present state (Exhibit 8.4) and outcome state (Exhibit 8.5) side by side. The present state in this case shows six primary health care problems related to the keystone issue: delirium tremens, encephalopathy, harmful use of alcohol, poor support system, medication-compliance issues, and lack of physical exercise.
The outcome state shows six matching goals to be achieved through care coordination: stabilization of delirium tremens, resolution of encephalopathy, permanent cessation of alcohol, recognition of community and personal support programs, medication compliance, and cardiac rehabilitation. Putting the two states together creates a gap analysis that naturally shows where the patient is and what the goals are in terms of the patient’s care. Some key questions to ask here: Are the outcomes appropriate given the diagnoses? Are there gaps between the outcomes and present state? Are there clinical indicators of the desired outcome state?
