CHAPTER 14

CARE COORDINATION FOR LONG-TERM CARE OF THE ADULT PATIENT

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 long-term care. The advanced practice nurse is working with a family that is in need of support services to promote quality outcomes at the end of life. 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 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 an individual plan of care using the Outcome-Present State-Test (OPT) model worksheets. In order to do this, one activates the patient-centered systems-thinking skills for complex patient stories and habitually uses key questions to reflect on the specific sections of the model (Pesut, 2008), as well as the dimensions of the 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 an 81-year-old African American female, Fanny White, who is a resident in a long-term care skilled nursing facility. She has been on the memory care unit for the past year and her care is managed by a geriatric nurse practitioner. One day a certified nursing assistant reported that he was having difficulty getting her out of bed to go to the dining room for lunch because of increased fatigue and lethargy. The baseline at this facility is to use one assist for transfers. On this day, Ms. White required two assists to transfer from the bed to the wheelchair. The staff reports a progressive general functional decline after Ms. White was admitted to the hospital for pneumonia 4 months ago. She has been experiencing decreased appetite and weight loss. Ms. White’s history includes 25-pack-years of smoking; however, she quit 2 months ago. Other comorbidities are Alzheimer’s-type dementia, hypertension, rheumatoid arthritis, impaired fasting glucose, chronic obstructive pulmonary disease, and depression.

The physical examination reveals an elderly African American female slumped over in a wheelchair. She has oxygen therapy at 2 L/min via nasal cannula. She responds to her name by attempting to lift her head and open her eyes. Her speech is garbled and incoherent compared to her usual baseline status. Demographic characteristics include height of 62 inches, blood pressure of 70/40 mmHg, heart rate of 70 beats/minute, weak and thready radial pulse, and oxygen saturation of 85%. Her body mass index for the past 5 months is described in Table 14.1.

Laboratory values are as follows—white blood count: 4.60/mm³, hemoglobin: 12.5 g/dL, hematocrit: 38.4%, blood urea nitrogen: 12 mg/dL, creatinine: 0.9 g/dL, estimated glomerular filtration rate: 73 mL/min, glucose: 93 g/dL, potassium: 4.8 mEq/L, calcium: 8.3 mEq/L, chloride: 97 mEq/L, sodium: 130 mEq/L, carbon dioxide: 23 mEq/L, prealbumin: 10 mg/dL, and albumin: 2.6 g/dL. The patient’s daily oral medications include Norvasc, naproxen sodium, Prilosec, Zoloft, Zofran, Marinol, and Mighty protein shakes.

PATIENT-CENTERED PLAN OF CARE USING OPT WORKSHEETS

Once the story is obtained from all possible sources, care planning proceeds using the OPT clinical reasoning web worksheet (Figure 14.1), 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 pinpoint 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 combined with medical conditions. The long-term care conditions in this case are history of Alzheimer’s dementia, chronic obstructive pulmonary disease, and comorbidities. 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 adult failure to thrive and imbalanced nutrition: less than body requirements.

TABLE 14.1 Body Mass Index

To spin and weave the web providers use 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 systems thinking and making 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 14.1 Outcome-Present State-Test clinical reasoning web worksheet.

COPD, chronic obstructive pulmonary disease; ICD-10, International Classification of Diseases, 10th edition.

TABLE 14.2 Relationships Among Nursing Domains, Medical Diagnoses, and Web Connections

Source: World Health Organization (2015).

The OPT clinical reasoning web worksheet in Figure 14.1 shows a template with the patient health care situation, medical diagnoses, and nursing diagnoses in 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 keystones, in this case perception and cognition and coping and stress tolerance. 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 14.2 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 the 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 14.2. As the advanced practice nurse thinks about the patient, he or she 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 14.3 (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 over to a care coordination model and team-centered systems thinking that considers patient and family preferences within the frame of the situation.

The patient-in-context story (Exhibit 14.1) is on the far right-hand side, as depicted in Figure 14.2. The advanced practice nurse notes relevant facts of the story, which in this case include the patient demographics and characteristics; 81-year-old African American female residing in a long-term care facility on a memory unit. She has a diagnosis of Alzheimer’s dementia, depression, malnutrition, and several comorbidities. Her failure to thrive has placed her in the caseload of a geriatric nurse practitioner who is to assist the family in making some end-of-life decisions about resuscitation as a result of Ms. White’s functional decline. Significant laboratory data show hypotension and oxygen dependency caused by chronic obstructive pulmonary disease and poor nutritional status, which has affected electrolyte levels, protein balance, and body mass index. Assessment of her medication regimen requires some needed adjustments as a result of hypotension and lethargy on physical examination. A key point at this juncture is to review and reflect on the patient story for accuracy and thoroughness to be able to proceed with care planning for care coordination.

TABLE 14.3 Questions That Guide the Use of the OPT Model

OPT, Outcome-Present State-Test.

Adapted from Pesut (2008).

FIGURE 14.2 Outcome-Present State-Test clinical reasoning model for care coordination worksheet.

BP, blood pressure; COPD, chronic obstructive pulmonary disease; DNR, do not resuscitate; GERD, gastroesophageal reflux disease; HTN, hypertension.

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 14.2). At the bottom of this box are placed the designated keystone issues or themes that fall under the most significant nursing domain—Alzheimer’s dementia F02.80 and depression F03.90. 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 14.3). The frame of this case is an elderly African American female in a long-term care unit admitted with failure to thrive. This 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. A key question to ask here is: How do I frame the situation and does the frame agree with the patient–family view of the situation?

At the center of the sheet are spaces to place the present state (Exhibit 14.4) and outcome state (Exhibit 14.5) side by side. The present state in this case shows five primary health care problems related to the keystone issues: malnutrition, weight loss, end-stage dementia, blood pressure 70/40 mmHg, and full resuscitation status. The outcome state shows five matching goals to be achieved through care coordination: comfort feedings, change focus to comfort care, end-of-life care with dignity, comfort hydration, and do-not-resuscitate status—comfort care. 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?

 

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EXHIBIT 14.4 PRESENT STATE

  1.  Malnutrition

  2.  Weight loss

  3.  End-stage dementia

  4.  Blood pressure: 70/40 mmHg

  5.  Full resuscitation status

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