CHAPTER 13

CARE COORDINATION FOR A PATIENT IN REHABILITATION

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 a patient in rehabilitation. The case presented in this chapter illustrates how an advanced practice nurse works with a patient who is in need of interventions during a cardiac rehabilitation process. The rehabilitation unit was prescribed for this patient after a hospital admission for chest pain and a percutaneous transluminal coronary angioplasty (PTCA) and stent placement into the left anterior descending (LAD) and circumflex (CMX) arteries. 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, 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, 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 processes.

LEARNING OUTCOMES

After completing this chapter, the reader should be able to:

THE PATIENT STORY

We begin with the history and story of a 45-year-old male, Derek Roberts, who presents to the cardiac rehabilitation unit after a percutaneous transluminal coronary angioplasty (PTCA) procedure with stent placement in two arteries. He was having some chest pain at work, his coworkers called 911, and he was brought to the emergency department for evaluation. He subsequently was taken to the cardiac catheterization laboratory for definitive care. After recovery in the coronary care unit, he was referred to the rehabilitation unit for cardiac conditioning and education regarding diet, exercise, medications, and lifestyle guidance to prevent further cardiovascular disease progression.

During admission to the rehabilitation unit, Derek appears tired and unmotivated to begin the rehabilitation process. His motivation is advice from his physician and encouragement from his wife “nagging him to take better care of himself.” He denies being angry about his heart condition and does not understand the regimen he needs to follow to prevent further cardiac events. He reports a lot of pain at the catheter puncture site in the right groin. He is limping and having difficulty walking on the treadmill.

Mr. Roberts’s past medical history includes the comorbidities of hypertension, type 2 diabetes mellitus, and sleep apnea. He is a nonsmoker at this time since quitting 5 years ago. He drinks approximately six beers per week. His social history includes that he is married and lives with a teenage son. He works full time as an auto mechanic, has returned to work, but takes the time to come to continue with cardiac rehabilitation. Current medications include Plavix 75 mg daily, aspirin 325 mg daily, Lipitor 20 mg at bedtime, lisinopril 10 mg daily, and Glucophage 500 mg three times daily.

The physical examination reveals a height of 5’ 11”, weight of 197 pounds (89.5 kg), and a body mass index (BMI) of 27.5. His lungs are clear, there are no abnormal heart sounds, and the telemetry monitor during exercise shows sinus rhythm with occasional unifocal premature ventricular contractions (PVCs). During exercise, his heart rate ranges 70 to 100 beats per minute, respiratory rate is 22 breaths per minute, and his oxygen saturation is 97%. Finger-stick blood sugar pre-exercise is 242 mg/dL, and post-exercise it is 100 mg/dL. His right groin has a large hematoma at the catheter puncture site.

Other laboratory values are as follows—nonfasting blood glucose: 240 mg/dL, sodium: 137 mEq/L, potassium: 3.9 mEq/L, total cholesterol: 179 mg/dL, low-density lipoprotein (LDL): 85 mg/dL, triglycerides: 189 mg/dL, and high-density lipoprotein (HDL):LDL ratio: 0.5.

PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS

Once the story is obtained from all possible sources, care planning and reasoning proceed using the OPT clinical reasoning web worksheet (Figure 13.1), which helps determine relationships among issues and highlights 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 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 hypertension, coronary artery disease, nicotine dependence in remission, type 2 diabetes mellitus, hyperglycemia, hypertriglyceridemia, difficulty walking, reaction to severe stress—unspecified, alcohol abuse, fatigue, pain in right leg, nontraumatic hematoma of soft tissue, problems in relationship with spouse, adjustment disorder with depressed mood, and sleep apnea. 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 fatigue, knowledge deficit, and ineffective self-help management.

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 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 13.1 Outcome-Present State-Test clinical reasoning web worksheet.

DM, diabetes mellitus; ICD-10, International Classification of Diseases, 10th edition.

An OPT clinical reasoning web worksheet, depicted in Figure 13.1, 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 the circles display the priority problem or keystone, in this case, health promotion. 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 helps 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 does the clinical reasoning web reveal 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 13.1 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 13.1. 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 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 13.2 (Pesut, 2008).

TABLE 13.1 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

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 that considers patient preferences within the frame of the situation.

The patient-in-context story (Exhibit 13.1) is depicted on the far right-hand side in Figure 13.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics: 45-year-old White male who lives with his wife and teenage son. He has diagnoses of coronary artery disease, hypertension, obesity, type 2 diabetes mellitus, hypertriglyceridemia, sleep apnea, alcohol abuse, fatigue, stress, depression, problems in relationship with spouse, difficulty walking, and pain in right leg from hematoma of soft tissue. He is post–PTCA and stent placement for occlusions in two cardiac arteries. He has returned to work as a mechanic and comes to the cardiac rehabilitation unit for education, exercise training, and lifestyle guidance. He abuses alcohol and stopped smoking 5 years ago. He also has some financial difficulties at home. The acute care nurse practitioner will pull the acute care team together to promote his health and manage his chronic comorbidities while working with him in the rehabilitation program. Significant laboratory data show hyperglycemia, hypertriglyceridemia, and a BMI of 27.5. 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 13.2 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from Pesut (2008).

Moving to the left, there is a place to list the diagnostic cluster cues on the web of medical diagnoses and ICD-10 codes (Exhibit 13.2). At the bottom of this box is placed the designated keystone issues or themes that fall under the most significant nursing domain—health promotion and coronary artery disease I25.10. Remember diagnostic cluster cue web logic is the use of inductive and deductive /thinking skills. The key question to ask here is: What diagnoses were generated, is there evidence to support those diagnoses, and 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 13.3). The frame of this case is a 45-year-old White male who presents to the rehabilitation unit post–PTCA and stent placement. He is fatigued and unmotivated to proceed with the cardiac rehabilitation program. He has a limp from soft tissue injury to the right groin. This frame helps to organize the present state and 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 the frame agree with the patient 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 13.4) and outcome state (Exhibit 13.5) side by side. The present state in this case shows five primary health care problems related to the keystone issue: fatigue, sleep apnea, several combined chronic disease conditions, uncontrolled type 2 diabetes mellitus, and knowledge deficit of his medical conditions.

The outcome state shows five matching goals to be achieved through care coordination: hemodynamic stabilization to correct nocturia, proper-fitting continuous positive airway pressure (CPAP) mask and compliance with that therapy, stabilization of disease conditions, regulation and stabilization of glucose levels, and knowledgeable and compliant with medical regimen. 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: 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?

FIGURE 13.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BMI, body mass index; CPAP, continuous positive airway pressure; DM, diabetes mellitus.

 

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EXHIBIT 13.4 PRESENT STATE

  1.  Fatigue

  2.  Sleep apnea

  3.  Several combined chronic disease conditions

  4.  Uncontrolled type 2 diabetes mellitus

  5.  Knowledge deficit of his medical conditions

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