CHAPTER 6

CARE COORDINATION FOR A PATIENT IN PRIMARY COMMUNITY HEALTH

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 a case given the context of primary community health care. The case presented in this chapter illustrates how an advanced practice nurse works with a family who is in need of health and wellness services to promote quality-of-life outcomes. The provider/clinic is the point of access for patients/families. 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, which will 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, community services, and living environments are determined and considered in managing care coordination and transitions (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, patient-centered systems-thinking skills are activated for complex patient stories and key questions are consistently used 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:

THE PATIENT STORY

We begin with the history and story of a 60-year-old African American female, Dorothy Smith, recently admitted into the Program of All-Inclusive Care for the Elderly (PACE). She lives with her brother and sister-in-law, who are her primary care providers. Ms. Smith recently moved from another state in a different region of the United Sates where she lived with another brother who recently passed away. She never married and has no children. She came to PACE (a primary community health clinic) with complaints of physical and verbal abuse from both her brother and sister-in-law. She was evaluated in the emergency department of the local hospital 2 days after she was injured as a result of a fall caused by her care providers. From the accident, she had a laceration that resulted in cellulitis of the lower right leg. The provider in the emergency department prescribed an antibiotic ointment for the laceration and discharged her to home. This leg is now painful to touch, erythematous, and swollen around the laceration.

The patient also reports financial exploitation from her caregivers as evidenced by their absconding with her food stamps and disability checks without sharing any of the resources with her. She states that her brother is trying to have her declared incompetent and he became “very angry” when he found out that she decided on a “do not resuscitate” (DNR) status on her medical record. This patient reports increased anxiety, difficulty sleeping at night, and a decreased appetite. She was placed in a skilled nursing facility (SNF) after she reported the abuse. Her brother was notified of the allegations and that adult protective services (APS) was contacted.

The physical examination and functional assessment reveal that she is wheelchair bound, but independent in mobilizing herself in the home. She is able to feed herself after meals are prepared and set up. She requires assistance with toileting, bathing, and dressing. This patient smokes cigarettes and has a 45-pack-year history (1 pack per day for 45 years). She scores 18 out of 21 on the Mini-Mental State Exam (MMSE) with an orientation of eight out of 10, and a recall of two out of three. Clock draw was normal.

The patient’s past medical history includes left hemiparesis after a cerebral vascular accident, which resulted in wheelchair dependency. She also has a history of hypertension, hyperlipidemia, gastroesophageal reflux disease (GERD), vitamin D deficiency, recurrent urinary tract infections, morbid obesity, eczema, bilateral cataracts, mild cognitive impairment, and depression. Current medications include Plavix, Flexiril, Benadryl, hydrochlorothiazide, lisinopril, ranitidine, Tylenol, vitamin D₃, naproxen, and Keflex.

PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS

Once the patient story is obtained from all possible sources, care planning and clinical reasoning follow using the OPT clinical reasoning web worksheet (Figure 6.1) to help determine relationships among issues and to highlight potential keystone issues. The OPT clinical reasoning web is a graphic representation of the functional relationships between and among diagnostic hypotheses derived from the analysis and synthesis regarding how each element and issue of the story relates to 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 diagnoses as they are jointly considered with medical conditions. The chronic medical condition in this case is a history of cerebrovascular accident (CVA) with comorbidities. Once the advanced practice nurse considers these medical diagnoses, the nursing care domains associated with them are identified. The complementary nursing domains and diagnoses most appropriate in this case are risk for injury, falls, and other directed violence.

To spin and weave the web, 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 support 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:

FIGURE 6.1 Outcome-Present State-Test clinical reasoning web worksheet.

GERD, gastroesophageal reflux disease; ICD-10, International Classification of Diseases, 10th edition.

  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) has the highest priority for care coordination and most efficiently and effectively represents the keystone nursing care needs of the patient by counting the arrows that connect the medical problems (ICD-10 codes). In this case, counting 14 lines pointing to or from the nursing domain of safety and protection 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 consequences of physical abuse and the promoters of infection/cellulitis are the keystone issues for this case.

The OPT clinical reasoning web worksheet in Figure 6.1 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 that create the web effect 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 keystone, in this case safety and protection. A keystone issue is one or more central supporting element 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. Some key questions to ask here are: How the clinical reasoning web reveals relationships between and among the identified diagnoses? To what degree do these relationships make practical clinical sense according to the evidence and patient story? Table 6.1 offers 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 6.1. 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 an illustrative representation and to 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 6.2 (Pesut, 2008).

TABLE 6.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

GERD, gastroesophageal reflux disease.

Source: World Health Organization (2015).

TABLE 6.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-test.

Adapted from Pesut (2008).

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 outcome states. Once interventions and tests are decided, the plan of care transitions to a care coordination model and team-centered systems thinking that consider patient and family preferences within the frame of the situation.

The patient-in-context story (Exhibit 6.1) is depicted on the far right-hand side in Figure 6.2. The advanced practice nurse notes relevant facts of the story, which in this case include the following: the patient demographics and characteristics; history of abuse by family care providers; psychosocial issues of insomnia, anxiety, and fearfulness; physical disabilities of immobility, injury, and cellulitis; and the fact that the patient is wheelchair bound because of immobility from a CVA. Assessment reveals obesity with normal vital signs and slightly decreased oxygen saturation at rest. Pertinent laboratory data include a complete metabolic panel and complete blood count (CBC) all within normal limits. Dorothy had an elevated cholesterol level of 181 mg/dL; elevated hemoglobin, A1C 5.9; decreased vitamin D, 11.1 ng/m and some white blood cells; 3+ occult blood; and protein in the urine. A key step at this juncture is to review and reflect on the patient story for accuracy and thoroughness to proceed with care planning for care coordination.

FIGURE 6.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BMI, body mass index; BP, blood pressure; CBC, complete blood count; GERD, gastroesophageal reflux disease; Ht, height; HR, heart rate; O₂ sat, oxygen saturation; RR, respiratory rate; Wt, weight.

Moving to the left of the model worksheet, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 6.2). At the bottom of this box are placed the designated keystone issues or themes that fall under the most significant nursing domain—adult physical abuse (T76.11) and cellulitis (L03.115). 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?

At 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 6.3). The frame in this case is elder abuse with concurrent physical impairments. This frame helps organize the present state and the 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. Some 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?

At the center of the sheet are spaces to place the present state (Exhibit 6.4) and outcome state (Exhibit 6.5) side by side. The present state in this case shows six primary health care problems related to the keystone issue: verbal, physical, and financial abuse by care givers; cellulitis in right lower leg; insomnia, anxiety, and fearfulness; nonadherence to medical regimen; sedentary lifestyle; and nonadherence to cardiac diet. The outcome state shows six matching goals to be achieved through care coordination: supportive safe care environment free from abuse; cellulitis healed within 14 days; Hamilton Anxiety Scale score less than 30 at next visit; BP normal limits—compliant with medications; engages in physical activity for mobility level; and adheres to cardiac diet. 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 whether the outcomes are appropriate given the diagnoses, whether there are gaps between the outcomes and present state, and whether there are clinical indicators of the desired outcome state?

The gap between where the patient is and where the advanced practice nurse wants the patient to be is one way to create a test (Exhibit 6.6). Clinical decisions are choices made about interventions that will help the patient transition from the present state to a desired outcome state. As interventions are tested, the advanced practice nurse evaluates the degree to which outcomes are or are not being achieved. The tests chosen in this case include Elder Mistreatment Assessment Tool, Braden Scale, Hamilton Anxiety Rating Scale, vital signs, and laboratory testing (CBC, vitamin D, and lipid profile).

 

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