Running head: APRN-LED TRANSITIONAL CARE PROGRAM

Advanced Practice Registered Nurse Led Transitional Care Program in an Accountable Care
Organization
Kala Sugathan
Arizona State University

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Abstract
Purpose: Reduce or prevent readmissions among heart failure (HF) patients and increase
quality of life (QOL), self-care behavior (SCB) and satisfaction through an advanced practice
registered nurse (APRN) led transitional care program (TCP) in collaboration with an
Accountable Care Organization (ACO).
Background: Hospital readmissions place a heavy financial burden on patients, families, and
health care systems. Readmissions can be reduced or prevented by providing a safe transition
through care coordination and enhanced communication. Research demonstrates
implementation of APRN led home visits (HV) along with telephonic follow-up are cost
effective and can be utilized for reducing readmissions among HF patients.
Methods: A program was designed with an ACO and carried out in a family practice clinic
with a group of seven HF patients older than 50 years who were at risk of readmission.
Interventions included weekly HV with supplemental telephonic calls by the APRN student
along with a physician assistant for 12 weeks. Readmission data was collected. QOL and SCB
were measured using “Minnesota Living with Heart Failure Questionnaire” (MLHFQ) and
“European Heart Failure Self-Care Behavior Scale” respectively. Data was analyzed using
descriptive statistics and the Friedman Test.
Outcomes: There were no hospital readmissions at 30 days and the interventions demonstrated
a positive effect on QOL, self-care management and satisfaction (χ2 = 30.35, p=.000). The
intervention had a large effect on the outcome variables resulting in an increase in QOL and
SCB scores post-intervention (ES= -1.4 and -2 respectively).
Conclusions: TCP designed with an ACO, carried out in a primary care setting has a positive
effect on reducing hospital readmissions and improving QOL, SCBs, and patient satisfaction

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among HF patients. TCPs are not revenue generating at outset due to reimbursement issues,
however future considerations of a multidisciplinary team approach with convenient workflow
may be explored for long-term feasibility and sustainability.
Funding Source: American Association of Colleges of Nursing and the Centers for Disease
Control and Prevention with support of the Academic Partners to Improve Health.
Keywords: Heart failure, Hospital readmissions, Transitional care, Home visits, Telephonic
call.

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Advanced Practice Registered Nurse Led Transitional Care Program in an Accountable Care
Organization
Introduction
Unnecessary or preventable hospital readmissions are a financial burden for the United
States healthcare system. Heart failure (HF) is one of the major reasons for readmissions and
healthcare costs. Recurrent admissions have an impact on the quality of patients’ life, selfmanagement, and functional status; worsens the disease process, renounces hope, and turns
into an affliction to the care giver/family. At present, policymakers and health care providers
are focused on the goals of improving excellence of care and decreasing hospital readmissions,
and the overall cost of care.
Background/Significance
Heart failure patients often do not receive the level of care required for a safe transition
from hospital to home, which increases the incidence of readmission, escalates healthcare
costs, and reduces quality of life (QOL). Approximately, one in five Medicare beneficiaries is
readmitted within 30 days of hospitalization (Shams, Ajorlou & Yang, 2015). These are
unplanned hospitalizations and 75% of these admissions could be prevented saving
approximately $17 billion dollars (Shams, Ajorlou & Yang, 2015). In an analysis of Medicare
fee-for-service claims data from 2007-2009, the 30-day readmission rate for HF patients was
24.8% (Dharmarajan et al., 2013). As part of discovering innovative ways to reduce total cost
per patient, the Medicare Shared Savings Programs (Section 3022) was established. In this
program, Accountable Care Organizations (ACO) are required to submit performance data
related to care transitions and reimbursement is based on quality of care and patient outcomes
(Naylor, Aiken, Kurtzman, Olds, & Hirschman, 2011).

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As part of the data collection and analysis under the Medicare Shared Savings Program
(MSSP), an ACO in the southwestern United States (U.S.) has identified a need to improve the
hospitalizations and readmission rates. A target practice site was identified as having increased
hospital readmissions above the ACO benchmarks. In this site, the total number of Medicare
patients is 2077; there were 36 and 40 all-cause readmissions in 2014 and 2015 respectively
(Donkerbrook, L., personal communication, March 04, 2016). Currently the office has same
day appointments available for sick patients, 24-hour triage line; pre-discharge interviews and
post discharge home visit by a case manager to assess needs of the patient within the home
setting. With these available resources, there is a communication gap between the provider and
the patients. Providers find they are unable to provide continuity of care that the patients need
for a safe transition out of the hospital and prevent the incidence of readmission.
Several factors that influence hospital readmissions include lack of access to a primary
care provider (PCP), complications during hospitalization, lack of social support, or
community resources, poor socioeconomic status, illiteracy, unawareness of disease process,
cognitive impairment, co-morbid conditions or underlying disability, poor adherence to
medications and treatment plan, medication errors, missed discharge follow up and lack of
structured discharge communication (Rennke & Ranji, 2015). Despite having insurance, more
than 50% of patients have no contact with their primary care physician between their first
hospitalization and their readmission (Kripalani et al., 2007). Due to rising healthcare costs,
interventions aimed at preventing HF readmissions, transitional care interventions (TCI) have
emerged.
Transitional care interventions. Multiple systematic reviews and meta-analysis
concluded that home visiting programs, multidisciplinary HF clinic interventions and telephone

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support reduced HF readmissions as well as mortality rates (Feltner et al., 2014; Naylor, Aiken,
Kurtzman, Olds & Hirschman, 2011). TCIs including weekly home visits alone for a month or
in combination with telephone calls showed an increase in patient's QOL and decrease in the
number of readmissions and health care costs among individuals with HF (Courtney et al.,
2012; Stamp, Machado & Allen, 2014). According to Vedel and Khanassov (2015), highintensity TCIs (combining home visits with telephone follow-up, clinic visits, or both) reduced
HF readmission risk regardless of the duration of follow-up. A systematic review and metaanalysis of 42 randomized control trials concluded that patient education, home visits, selfmanagement support and case management are effective in reducing all cause 30-day
readmission rates and improving patient capacity for self-care (Leppin et al., 2014). A quasiexperimental prospective cohort study evaluated the effectiveness of care transitions
interventions and appeared to be successful in reducing all cause 30-day readmissions among
fee-for-service Medicare patients. The interventions include a coach completing a hospital
visit, a home visit and two follow-up telephone calls (Voss, Gardner, Baier, Butterfield,
Lehrman & Gravenstein, 2011).
Role of advanced practice registered nurses. Heart failure patients confront
challenges in modifying self-care behaviors (SCB) to maintain health. Advance practice
registered nurses (APRNs) play an important role in coordinating care and providing
education. A systematic review indicated that APRNs provide effective and high quality care
to patients (Newhouse et al., 2011). A prospective study completed by Stauffer et al. (2011),
found that APRN led TCIs were effective and reported to have a decrease in 30-day HF
readmission rates as well as overall cost of care. In an RCT, Brandon, Schuessler, Ellison and
Lazenby (2009) evaluated the effect of APN led telephonic intervention on hospital

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readmissions, QOL and SCBs of HF patients and the results showed a positive impact on
outcomes of HF patients by reducing readmissions and improving QOL and SCBs.
Search Strategy
The initial review for an effective intervention has lead to the clinically appropriate
PICOT question, “In patients (> 50 years old) with heart failure (P), how does weekly home
visit with a telephonic follow up by an advanced practice provider (I) compare to standard of
care (C) affect 30-day readmission rates (O) over a 12 week period (T)?”
An extensive electronic search was performed to retrieve pertinent studies to answer
the PICOT question. The databases utilized for this review included Cumulative Index to
Nursing and Allied Health Literature (CINAHL), 2005-2015, PubMed, 2011-2016, Cochrane
database, and The Joanna Briggs Institute Database of Systematic Reviews and
Implementation Reports, 2011-2016. Limits including English language and human subjects
were applied to the search. The key words used for the search were heart failure readmissions,
transitional care interventions, transitional care management, home visits, home based
interventions and advanced practice nurses. A total of 15 studies were selected for evaluation.
From that intitial group, several systematic reviews were excluded due to the similarity of the
studies and variables examined. Ten studies relevant to the PICOT question were chosen for
critical appraisal and synthesis of evidence.
Synthesis of Evidence
In general, the selected studies were of high quality and included six randomized
controlled trials (RCTs) of level II evidence, three systematic reviews of level I, and one
prospective study of level III evidence (Melnyk & Fineout-Overholt, 2015). The evidence
suggests that TCIs conducted in different settings can have a positive effect on reducing

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hospital readmissions, mortality and improving QOL, SCB, cost savings and patient
satisfaction among HF patients (Aguado et al., 2010; Biese et al., 2014; Courtney et al., 2012;
DeWalt et al., 2006; Feltner et al., 2014; Leppin et al., 2014; Naylor et al., 2004; Stauffer et al.,
2011; Wong, Chow, Chan & Tam, 2014). A significant effect is reported when interventions
were bundled in the TCP. Home visit together with telephonic follow-up had the greatest effect
in reducing readmissions. A significant effect on TCI outcomes was observed with APRN-led
interventions. At least eight home visits (once weekly for the first four weeks and once in
alternate weeks for next eight weeks) were conducted in two of the studies. The time frame of
the interventions for most of the studies was 12 weeks (3 months) but there was no difference
in outcomes resulting from differences in length of interventions. Across studies, the
instrumentation was valid and reliable. Instrumentation included Instrumental Activities of
Daily Living scale, Minnesota Living with Heart Failure Questionnaire, self-efficacy scale,
Short Test of Functional Health Literacy in Adults (STOFHLA), European Heart Failure SelfCare Behavior Scale, Short Form -36 questionnaire and Chronic Disease Self-Efficacy Scale.
In conclusion, evidence from this review strongly suggests that implementation of
APRN-led home visit along with telephonic follow-up will be cost effective and can be utilized
for reducing readmissions among HF patients.
Purpose
The purpose of the project was to develop an APRN led transitional care program
(TCP) with an ACO to implement in a family practice clinic to reduce or prevent readmissions
among HF patients and increase patients’ QOL, SCB and satisfaction.

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Evidence Based Practice Model Chosen to Guide Project Development
The Iowa Model of Evidence-Based Practice to Promote Quality Care aids clinicians in
making decisions that will have an impact on patient outcomes (Titler et al., 2001). This model
is known for its applicability and ease of use by multidisciplinary healthcare teams. A team
was formed for the TCP that included a physician, physician assistant (PA), pharmacist, case
manager and registered nurse who was the co-investigator on the project. The Iowa model was
chosen to implement an evidence based practice (EBP) program for reducing readmissions
because this model clearly explains the steps for changing a practice and assists users in
adhering to the principles of EBP (Appendix A). The steps include identification of a clinical
problem, literature review and evidence synthesis, piloting a practice change, evaluation of the
pilot and outcomes, and finally dissemination of results (Titler et al., 2001).
Theoretical/Conceptual Framework
Dorothea Orem’s Self-Care Theory which highlights the significance of being
independent for one’s own care (Orem, 2001) and Afaf Meleis’s Theory of Transition which
provides a guide to moving a patient from one setting to another (Meleis, Sawyer, Im, Messias,
& Schumacher, 2000) can inform the design of interventions that improve patient
outcomes. According to Orem’s theory, a patient’s knowledge of health problems is required
for improving self-care behaviors (Orem, 2001). The main challenges associated with heart
failure patients are lack of knowledge and improper performance of self-care. Current evidence
shows that patients who perform self-management behaviors enhance their health outcomes.
During the home visit, patient education on self-care behaviors was provided to improve selfcare behaviors and functional status and increase the quality of life. Transition theory was used

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to help the TCP team to analyze the goals, feelings and behaviors necessary for the patients to
adjust to the new situation and transitioning (Smith & Parker, 2015).
Methods
Ethical Considerations
An approval letter including the permission to access the health records was obtained
from the Medical Director of the clinical practice (Appendix B). Arizona State University
institutional review board approved the project as an Expedited Review (Appendix C).
Informed consent was obtained from participants prior to their engagement in the project
(Appendix D).
Practice setting and Participants
The project site was a family practice clinic in a metropolitan area in the southwestern
U.S. There are three physicians, eleven PAs and a chiropractor. The patients were identified by
the clinical site supervising physician or the PA and the project was introduced to the potential
participants. Inclusion criteria for patients were age > 50 yrs, English speaking, able to read
and write English, Medicare or Medicare Advantage beneficiaries and heart failure patients
recently discharged from the hospital or at risk of readmissions. The potential participants were
invited by the co-investigator to participate in the project and a group of seven patients was
enrolled.
Intervention
In the initial phase, the team formed for the TCP included a physician, PA, pharmacist,
case manager and registered nurse/co-investigator. A pharmacy that delivers medications to the
home at no extra cost was included in this program to ensure the timely availability of
medications. The intervention period was 12 weeks for each participants and patients were

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enrolled during the first three weeks of the intervention period. Patients were offered the home
delivery pharmacy service; changing their pharmacy was not mandatory. Weekly home visits
were conducted by the co-investigator along with the PA for 12 weeks and included physical
assessment, vital signs, medication reconciliation or adjustment if needed and patient education
on medications, self-care behaviors, and symptom management. During the first visit, patients
were provided with education materials, a blood pressure (BP) machine, weighing scale, BP
and weight log, pill cutter, pill organizer and a gift card ($25.00). Patients were encouraged to
check their BP, heart rate and weight daily and maintain a log. The initial home visit took
approximately one hour and the subsequent visits took an average of 25 minutes. A
supplementary telephonic call was made weekly to check on patients, maintain a good
relationship, build trust and assure the continuity of care. In addition, participants were
provided with a 24-hour triage line and the office number with the extension to the medical
assistant of the PA to report any changes. The ACO case manager arranged home health or
physical therapy for the patients as needed. The supervising physician was updated weekly by
the PA and the co-investigator on patients’ status, needs, deficits and services provided. The
program effectiveness was evaluated every four weeks by conducting meetings with the TCP
physician to evaluate the strengths, weaknesses, flaws and to discuss ways to improve the
program based on the evaluation.
Outcome Measures
The primary outcome in this project was the number of hospital readmissions at 30
days post discharge. The secondary outcomes were patients’ quality of life, self-care behaviors
and satisfaction.

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Instruments
A demographic questionnaire (Appendix E) was developed to collect information on
patient demographics and information on chronic conditions, HF management, last
hospitalization and number of emergency room and hospitalizations in the past six months.
Pre and post intervention QOL was measured using Minnesota Living with Heart
Failure Questionnaire (MLHFQ) (Appendix F). Permission was obtained from University of
Minnesota Office for Technology Commercialization. The MLHFQ is a self-administered
questionnaire that has 21 questions rated on a six-point Likert scales with a total score range
from 0 to 105 (from best to worst) which represents various degrees of impact of HF on health
related QOL (University of Minnesota, 2016). This tool has been evaluated for the
applicability, internal consistency, and validity and found high internal consistency with
Cronbach’s α > 0.7 (Naveiro-Rilo et al., 2010).
The European Heart Failure Self-Care Behavior Scale ((EHFScB), a 9-item selfadministered questionnaire was used to measure the pre and post intervention self-care
behavior (Appendix G). A 5-point Likert scale is used and the score range is from 9 to 45, with
the lower number pointing towards better self-care (Lee et al., 2013). Permission to use this
questionnaire was obtained from the author. The reliability for the nine-item scale was
acceptable (0.80) and Cronbach's alpha ranged from 0.68 and 0.87 across different countries
(Jaarsma, Arestedt, Martensson, Dracup & Stromberg, 2009).
Patient satisfaction was measured by offering a satisfaction survey rated on a five-point
Likert scale (Appendix H). This survey was developed by the co-investigator; validity was
established by two experts who are nurse practitioners with experience in primary care and
managing patients pre and post hospital discharge.

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Data Collection and Analysis
Post intervention QOL, SCB and satisfaction surveys were collected after the 12th week
home visit. Hospital readmission data was collected through tracking hospital admission data
from the health records and patient reports. All data analyses were performed using Statistical
Package for the Social Sciences (SPSS) version 23 with a statistical significance level set at ≤
.05. Friedman test was performed since there were more than two measurements/outcome
variables (QOL, SCB and satisfaction) from same participants.
Budget
Total costs for the project were estimated to be $14,526.00 (Appendix I). In-kind
support in the amount of $10,558.00 was provided by the project site. A $4,000 grant to cover
the balance of the cost was awarded by the American Association of Colleges of Nursing and
the Centers for Disease Control and Prevention (AACN/CDC) with support of the Academic
Partners to Improve Health (APIH) (Appendix J).
Results
Demographic Data
Twelve patients were eligible for the project; three refused the home visits and two
were not Medicare/Medicare Advantage beneficiaries. The average age of the remaining
patients (n = 7) was 79 (SD = 6.74) years and the ages ranged from 70 to 90 years of age. Most
of the participants were females (71%, n = 5) and males were 29% (n = 2). All participants
were Caucasian and retired (100%, n = 7); 57% were married and 43% were either single or
widowed. Seventy-two percent of the participants had either college or doctoral degree as
education. The cardiologist was mainly managing the heart failure for most of the participants
(86%) and all the participants had an average of two chronic conditions (SD = .577). The

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average number of prescription medications was 11 (SD = 1.38) and all the participants scored
well for social support. All of the participants had either an emergency room visit (SD = 1.55)
or a hospitalization (SD = 1.11) in the past six months (Appendix K, Table 2).
Outcomes
Readmissions. There were no readmissions at 30 days post discharge (SD=.00). There
was one readmission after 30 days and one direct admit after 30 days (SD=.38) (Table
3).
Quality of life. The average score for pre-intervention QOL was 49 (SD=13.29) with
the median score of 51 and the total score ranged from 32-72. Post-intervention, the
average score dropped to 30 (SD=10.19), median score to 27 and the total score ranged
from 18-43. The lesser number indicates improved QOL post intervention (Table 4).
Self-care behavior. The mean score for pre-intervention SCB was 25 (SD=5.56) with a
median score of 24 and the total score ranged from 17-34. A lesser score signifies better
self-care. After intervention, a significant improvement was noticed in the self-care
behaviors with a median and mean score of 14 (SD=2.14) and a total score ranged from
12 to 17 (Table 5).
Satisfaction. All the patients were satisfied with the TCP except for pharmacy service.
Only one patient used the home based pharmacy and was not satisfied with the service.
Due to variation in BP, frequent changes were made in this patient’s medication
regimen that contributed to the dissatisfaction. The mean satisfaction score was 24 (SD
= .38) with a median score of 24 and the total score ranged from 23 to 24 (Table 6).
A Friedman test demonstrated a positive effect from the interventions on patient’s
QOL, self-care management and satisfaction (χ2 = 30.35, p = .000) (Table 7). The average

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QOL and SCB mean score is significantly reduced which indicates better quality of care and
better self-management. The intervention had a large effect on the outcome variables resulting
in an increase in QOL and SCB scores post-intervention (Effect Size = -1.4 and -2
respectively).
Discussion
As evidenced by research, TCP conducted in the family practice clinic had a significant
effect on reducing readmissions and resulted in improved patient outcomes. This TCP was well
organized and helped the patients to increase their awareness and utilization of the transitional
care interventions. Patients were also educated on resources that are available for an
emergency in their PCP’s office like 24-hour triage line and an on-call physician services. TCP
encouraged the patients to use the urgent care instead of emergency room (ER) to reduce health
care cost. Developing and maintaining a relationship with the older population is very difficult.
Once the providers developed a rapport and gained the patients’ trust, the participants were
more cooperative and followed the instructions. The home delivery pharmacy within the
transitional care program was underutilized because most of the participants were enrolled in a
mail order pharmacy service.
Limitations and Implications
Small participant numbers was one of the limitations of this project and it was due to
limitations of the selection criteria and lack of patient-interest. The project focused on HF
patients and was designed for only Medicare beneficiaries due to limited data availability at the
ACO regarding the hospitalizations and ER visits for patients with other types of insurance.
The pool of patients could have been larger if more types of chronic conditions and insurance
coverage were included as eligible for the project. Reimbursement was another challenge

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encountered throughout the program. Medicare will pay the provider for transitional care
services once in 30 days per patient following a discharge. Home visit billing codes could not
be used for a family practice clinic since the practice is not credentialed to do home care.
Although, research indicates the benefit of weekly home visits for the first few weeks, it is not
in practice due to billing limitations. Some patients did not require 12 home visits; therefore
the project could have been designed for a minimum of 1-2 home visits and as needed for 12
weeks.
For hospital follow up visit in the office, the providers only get an average of 15
minutes to see the patient which is not sufficient for the clinicians to go through the health
records and discharge instructions; perform medication reconciliation, patient education and
history of physical illness for the current visit. Patients need supportive resources and more
education to promote daily functioning and self-care activities that helps with the transition.
Hence it is recommended to have a TCP in solo private practices to improve patient outcomes
and communication.
Doctoral projects can be embedded in local communities through partnerships with
growing ACOs to improve the quality of care in the community as well as to promote
sustainable changes in the organization and population. Timely and effective TCIs can reduce
readmissions of HF patients within 30 days of hospital admission and increase QOL, SCB and
satisfaction. TCPs are not revenue generating at outset due to reimbursement issues, however
future considerations of a multidisciplinary team approach with convenient workflow may be
explored for the financial benefits to support sustainability. The interdisciplinary team can be
cost and quality effective; the cost saving becomes the source of revenue to support the
program. Financial savings associated with the MSSP, high quality service and reduced health

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care costs would be some of the benefits to the ACO in the future. As soon as a suitable
workflow with multidisciplinary team is developed, TCP can be promoted and replicated in
other practices within this ACO.
Conclusion
The large gaps in care during transition from one setting to another can lead to unmet
needs, poor satisfaction with care and increased readmission rates. Avoidable
rehospitalizations are a costly burden for payers as well as for acute care hospitals. An APRN
led TCP was developed and implemented as part of an existing primary care practice setting to
improve the hospitalizations and readmission rates. Through this project, it is suggested that
successful TCPs might be conducted in any settings including private practices. TCPs facilitate
improved communication between the hospital and primary care providers as well as with the
patients, which in turn improves the patient outcomes and reduces length of hospital stay,
morbidity and mortality rates and healthcare cost.
The quality of services rendered to the patients could be improved through better coordination and enhanced communication. Patients may become more cooperative and
compliant with the treatment plan, which in turn may increase the patient’s functional status,
QOL and SCB. In conclusion, based on the results, the TCP was successful in reducing
hospital readmissions and increasing patients’ QOL, self-care management and satisfaction.
Either payment reform or innovative billing strategies may be required for sustainability of the
TCPs or a future effort will be crucial to develop a workflow with a multidisciplinary team
approach to achieve cost effectiveness.

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Rennke, S., & Ranji, S. R. (2015). Transitional care strategies from hospital to home: A review
for the neurohospitalist. The Neurohospitalist, 5(1), 35–42.
Shams, I., Ajorlou, S., & Yang, K. (2015). A predictive analytics approach to reducing 30-day
avoidable readmissions among patients with heart failure, acute myocardial infarction,
pneumonia, or COPD. Health Care Management Science, 18(1), 19-34.

APRN-LED TRANSITIONAL CARE PROGRAM

21

Smith, M. C., & Parker, M. E. (2015). Nursing theories and nursing practice (4th ed.).
Philadelphia, PA: FA Davis.
Stamp, K. D., Machado, M. A., & Allen, N. A. (2014). Transitional care programs improve
outcomes for heart failure patients. Journal of Cardiovascular Nursing, 29(2), 140-154.
Stauffer, B., Fullerton, C., Fleming, N., Ogola, G., Herrin, J., Stafford, P., & Ballard, D.
(2011). Effectiveness and cost of a transitional care program for heart failure: A
prospective study with concurrent controls. Archives of Internal Medicine, 171(14),
1238-1243.
Titler, M.G., Klieber, C., Steelman, V., Goode, C., Rakel, B. A., Budreau, G., Everett, L.Q., …
Goode, C.J. (2001). The Iowa model of evidence-based practice to promote quality
care. Critical Care Nursing Clinics of North America, 13 (4), 497-509
University of Minnesota. (2016). Minnesota Living With Heart Failure Questionnaire.
Retrieved from http://license.umn.edu/technologies/94019_minnesota-living-withheart-failure-questionnaire
Vedel, I., & Khanassov, V. (2015). Transitional care for patients with congestive heart failure:
A systematic review and meta-analysis. Annals of Family Medicine, 13(6), 562-571.
Voss, R., Gardner, R., Baier, R., Butterfield, K., Lehrman, S., & Gravenstein, S. (2011). The
care transitions intervention: Translating from efficacy to effectiveness. Archives of
Internal Medicine, 171(14), 1232-1237.
Wong, F. K. Y., Chow, S. K. Y., Chan, T. M. F., & Tam, S. K. F. (2014). Comparison of
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91–97.

APRN-LED TRANSITIONAL CARE PROGRAM
Appendix A

IOWA model of EBP

The Iowa Model of Evidence-Based Practice to Promote Quality Care (Titler et al., 2001)

22

APRN-LED TRANSITIONAL CARE PROGRAM
Appendix B
Clinical Site Authorization letter

23

APRN-LED TRANSITIONAL CARE PROGRAM
Appendix C
IRB Approval letter

APPROVAL: EXPEDITED REVIEW
Diane Nunez
CONHI - DNP
602/496-0751
DIANE.NUNEZ@asu.edu
Dear Diane Nunez:
On 8/19/2016 the ASU IRB reviewed the following protocol:
Type of Review:
Title:
Investigator:
IRB ID:
Category of review:
Funding:
Grant Title:
Grant ID:
Documents Reviewed:

Initial Study
Advanced Practice Nurse led Transitional Care Program to Prevent
Hospital Readmissions
Diane Nunez
STUDY00004742
(4) Noninvasive procedures, (7)(a) Behavioral research
Name: American Association of Colleges of Nursing

• Sugathan_ACO_ transitional care_Authorization letter.pdf, Category:
Off-site authorizations (school permission, other IRB approvals, Tribal
permission etc);
• Sugathan- Permission for using European Heart Failure Self-Care
Behavior Scale.pdf, Category: Other (to reflect anything not captured
above);
• Sugathan_Consent for Organizational Readiness Survey.pdf, Category:
Participant materials (specific directions for them);
• Nunez_2014_citiCompletionReport2224391.pdf, Category:
Vitaes/resumes of study team;
• Sugathan_EBP proposal.pdf, Category: Sponsor Attachment;
• Sugathan_Blood pressure & Wt log.pdf, Category: Participant
materials (specific directions for them);
• Sugathan_K_CITI Training2016.pdf, Category: Vitaes/resumes of
study team;
• Sugathan_TCP_Demographic Questionnaire.pdf, Category: Measures
(Survey questions/Interview questions /interview guides/focus group
questions);
• Sugathan_ TCP_Education on Exercise.pdf, Category: Participant
materials (specific directions for them);
• Sugathan_ PATIENT SATISFACTION SURVEY.pdf, Category:
Measures (Survey questions/Interview questions /interview guides/focus
group questions);
• Sugathan_measurement tool_EHFScB-9.pdf, Category: Measures
(Survey questions/Interview questions /interview guides/focus group
questions);
• Sugathan_Consent for Organizational Readiness Survey.pdf, Category:
Consent Form;
• Sugathan_HIPPA form for patients.pdf, Category: Off-site
authorizations (school permission, other IRB approvals, Tribal
permission etc);
• Sugathan_Diet and Congestive Heart Failure.pdf, Category: Participant
materials (specific directions for them);

24

APRN-LED TRANSITIONAL CARE PROGRAM

25

• Sugathan_Cover letter.pdf, Category: Consent Form;
• Sugathan_ esorganizationalreadinesssurvey.pdf, Category: Measures
(Survey questions/Interview questions /interview guides/focus group
questions);
• Sugathan_Minnesota Living with Heart Failure Questionnaire
permission.pdf, Category: Other (to reflect anything not captured
above);
• Sugathan_2016permission ASU_Organizational readiness.pdf,
Category: Other (to reflect anything not captured above);
• Sugathan_Cover letter.pdf, Category: Recruitment Materials;
• Sugathan_ Master list.pdf, Category: Other (to reflect anything not
captured above);
• Sugathan_Education_Exercise Tips.pdf, Category: Participant
materials (specific directions for them);
• Sugathan_Cover letter.pdf, Category: Participant materials (specific
directions for them);
• KSugathan_IRB Applicatin_Final.docx, Category: IRB Protocol;
• Sugathan_ measurement_MLHFQ_questionnaire_1_.pdf, Category:
Measures (Survey questions/Interview questions /interview guides/focus
group questions);
• Sugathan_Education_How Can I Keep My Heart Failure From
Worsening.pdf, Category: Participant materials (specific directions for
them);
• Sugathan_Student Privacy & Confidentiality Agreement.pdf, Category:
Off-site authorizations (school permission, other IRB approvals, Tribal
permission etc);
• Sugathan_Grant approval letter.pdf, Category: Sponsor Attachment;
• Sugathan_Recruitment_Flyer.pdf, Category: Recruitment Materials;
• Sugathan_HIPPA policies and procedures for the practice.pdf,
Category: Other (to reflect anything not captured above);
• Sugathan_Projected Costs.pdf, Category: Resource list;

The IRB approved the protocol from 8/19/2016 to 8/18/2017 inclusive. Three weeks before 8/18/2017 you are to submit a
completed Continuing Review application and required attachments to request continuing approval or closure.
If continuing review approval is not granted before the expiration date of 8/18/2017 approval of this protocol expires on that
date. When consent is appropriate, you must use final, watermarked versions available under the “Documents” tab in ERAIRB.
In conducting this protocol you are required to follow the requirements listed in the INVESTIGATOR MANUAL (HRP-103).
Sincerely,

IRB Administrator
cc:

Kala Sugathan
Kala Sugathan

APRN-LED TRANSITIONAL CARE PROGRAM

26

Appendix D
Cover letter and consent
Advanced Practice Nurse led Transitional Care Program to Prevent Hospital Readmissions
Dear Participant,
I am a graduate student under the direction of Professor Dr. Diane Nunez DNP, RN, ANP-BC, FNAP in the College
of Nursing and Health Innovation at Arizona State University. I am conducting an evidence based pilot program to see if an
advanced practice nurse led transitional care program will reduce or prevent readmissions and improve patient quality of life
and satisfaction.
I am inviting you to participate in the pilot program because you were identified as a potential participant by your
primary care physician due to the risk of being readmitted into the hospital. This project includes home visits with
supplemental telephonic calls for 12 weeks. Physical assessment, medication reconciliation, and education on medications,
self-care behaviors and symptom management will be performed during the visit. Initial data collected will include
demographic questionnaire. The home visit will be approximately 30 minutes and will be conducted once a week for 12 weeks.
The telephonic call which may take 2-3 minutes will be made once a week for 12 weeks to check on patients, maintain a good
relationship, build trust and assure the continuity of care. Post intervention survey will be completed to determine the impact of
the project on quality of life, self-care behavior and satisfaction. You have the right not to answer any questions, and to stop
participation at any time during the program.
Brisma Pharmacy does home delivery at no additional cost and accept all major insurance including Medicare,
Medicaid (AHCCCS) plans and Magellan. Researchers and project personnel have no affiliation or relationship with this
pharmacy. It is selected only for its geographic location to project site and potential participants. Participants having difficulty
in picking up medications from the pharmacy can change the pharmacy to Brisma pharmacy. Changing pharmacy is not
mandatory.
Your participation in this pilot program is voluntary. If you choose not to participate or to withdraw from the
program at any time, there will be no penalty. It will not affect the care you receive prior to, during, or after your participation
in the program. Participation in this project will not affect your treatment in the primary care clinic. You must be 50 years of
age or older to participate in this program. There is no known risk greater than those that are associated with everyday types of
activity.
Your responses on the questionnaires will be confidential and will be identified only by a number. The results of this
study may be used in reports, presentations, or publications, but the assigned ID number will not be connected to your name or
other personal identifying information. The ID number will be connected to names through a master list and the names will not
appear directly on any participant data forms and will be linked only with a list matching your name and ID number in a form
that will be kept confidential by the co-investigator.
The graduate student will have access to your health records from the clinic in order to document the care and
services rendered by the transitional care program into the electronic medical records. Agreeing to participate in this program
will be considered as your consent for the student to access the medical records. If you have any questions concerning this
program, please contact the following team members:
Kala Sugathan BSN, RN, DNP student at 480-826-3427
Dr. Diane Nunez, DNP, RN, ANP-BC, FNAP at 602-496-0751
If you have any questions about your rights as a participant in this project, or if you feel you have been placed at risk,
you can contact the Chair of the Human Subjects Institutional Review Board, through the ASU Office of Research Integrity
and Assurance, at (480) 965-6788.
Sincerely,
Kala Sugathan BSN, RN, DNP student
Dr. Diane Nuñez DNP, RN, ANP-BC, FNAP
By signing below you are agreeing to be part of the project.
Name:
Signature:

Date:

APRN-LED TRANSITIONAL CARE PROGRAM

27

Appendix E
Demographic Questionnaire
ID ______________

Date ____________

Transitional Care Project
Demographic Questionnaire
Please check the box that best corresponds to your answer or provide a response for each
question below
1. Age ____________
2. Gender Male
Female
3. Race/Ethnicity African American
Asian
Caucasian
Hispanic or Latino
Native Hawaiian or other Pacific Islander
Other (please specify): ___________________
4. Marital Status –
Married
Single
Divorced
Widow/Widower
Living with partner
6. Employment Status
Employed
Unemployed
Retired
7. Highest Level of education:
Less than High School graduate
High school graduate
Technical School
Some College
College degree
Masters degree
Doctoral degree
Post graduate degree

APRN-LED TRANSITIONAL CARE PROGRAM

28

8. Chronic conditions:
Diabetes Mellitus
COPD
Kidney disease
Arthritis
Asthma
High blood pressure
Other (please specify): ________________
9. Who is managing your heart failure?
Cardiologist
Primary care/Internal Medicine
None
10. How many prescription medications are you taking currently? ____________
11. Do you feel you have Social support (Family member/care giver), if so whom?
No
Yes
12. What is your current housing?
House
Rent
Apartment
Group home
Homeless
13. Last hospitalization ______________
14. Last Emergency Department visit ________________
15. How many times did you go to the Emergency during the past 6 months? _____________
16. How many times did you stay in a hospital during the past 6 months? ________________

APRN-LED TRANSITIONAL CARE PROGRAM

29

Appendix F
Instrument: Measure quality of life


MINNESOTA LIVING WITH HEART FAILURE QUESTIONNAIRE
The following questions ask how much your heart failure (heart condition) affected your life during the
past month (4 weeks). After each question, circle the 0, 1, 2, 3, 4 or 5 to show how much your life was
affected. If a question does not apply to you, circle the 0 after that question.
Did your heart failure prevent
you from living as you wanted during
the past month (4 weeks) by 1. causing swelling in your ankles or legs?
2. making you sit or lie down to rest during
the day?
3. making your walking about or climbing
stairs difficult?
4. making your working around the house
or yard difficult?
5. making your going places away from
home difficult?
6. making your sleeping well at night
difficult?
7. making your relating to or doing things
with your friends or family difficult?
8. making your working to earn a living
difficult?
9. making your recreational pastimes, sports
or hobbies difficult?
10. making your sexual activities difficult?
11. making you eat less of the foods you
like?
12. making you short of breath?
13. making you tired, fatigued, or low on
energy?
14. making you stay in a hospital?
15. costing you money for medical care?
16. giving you side effects from treatments?
17. making you feel you are a burden to your
family or friends?
18. making you feel a loss of self-control
in your life?
19. making you worry?
20. making it difficult for you to concentrate
or remember things?
21. making you feel depressed?

No

Very
Little

Very

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0

1

2

3

4

5

0
0

1
1

2
2

3
3

4
4

5
5

0
0

1
1

2
2

3
3

4
4

5
5

0
0
0
0

1
1
1
1

2
2
2
2

3
3
3
3

4
4
4
4

5
5
5
5

0

1

2

3

4

5

0
0

1
1

2
2

3
3

4
4

5
5

0
0

1
1

2
2

3
3

4
4

5
5

Much

©1986 Regents of the University of Minnesota, All rights reserved. Do not copy or reproduce without
permission. LIVING WITH HEART FAILURE® is a registered trademark of the Regents of the
University of Minnesota.

APRN-LED TRANSITIONAL CARE PROGRAM

30

Appendix G
Instrument: Measure self-care behavior
The European Heart Failure Self-Care Behavior Scale_9
This scale contains statements about heart failure self-care. Respond to each
statement by circling the number you think best applies to you. Note that the
different answer alternatives constitute a scale ranging between the extremes of “I
completely agree” (1) to “I don’t agree at all” (5). Even if you feel uncertain about
a particular statement, circle the number you feel is most true for you.
I don’t
agree at
all

I
completely
agree

1. I weigh myself every day

1

2

3

4

5

2. If my shortness of breath increases I contact
my doctor or nurse.

1

2

3

4

5

3. If my feet/legs become more swollen than
usual I contact my doctor or nurse.

1

2

3

4

5

4. If I gain 4.5 lbs in one week I contact my
doctor or nurse.

1

2

3

4

5

5. I limit the amount of fluids I drink (not
more than 1½-2 l/day: 6 to 8 cups)

1

2

3

4

5

6. If I experience increased fatigue I contact
my doctor or nurse

1

2

3

4

5

7. I eat a low salt diet

1

2

3

4

5

8. I take my medication as prescribed

1

2

3

4

5

9. I exercise regularly

1

2

3

4

5

The European Heart Failure Self-care Behavior Scale
(Jaarsma, Stromberg, Martensson, Dracup, 1999)

APRN-LED TRANSITIONAL CARE PROGRAM

31

Appendix H
Instrument: Patient Satisfaction Survey
ID ______________

Date ____________
PATIENT SATISFACTION SURVEY

Please read the following statements carefully and circle one number on each line which
indicates how strongly you agree or disagree.

Strongly
Disagree

Disagree Agree

Strongly
Agree

1

The TCP team provided adequate
information about the disease condition
and management.

1

2

3

4

2

The instructions were easy to follow.

1

2

3

4

3

I felt that I had enough resources to
manage my health condition.

1

2

3

4

4

I would rate the quality of services
provided by the advanced practice
providers as excellent.

1

2

3

4

5

I am extremely satisfied on home
delivery of medications.

1

2

3

4

6

Overall, I am satisfied with the TCP
providers and services
I will recommend this program to a
friend or a family member.

1

2

3

4

1

2

3

4

7

8

What did you like most about the TCP?

9

What aspects of the program could be improved?

APRN-LED TRANSITIONAL CARE PROGRAM

32

Appendix I
Table 1
Projected cost
Expense Item
Personnel
Project director (DNP student)
$40/hr for ~13 hrs per week X
12 weeks
Supervising Physician @75/hr
1hour/week for 12 weeks
Office staff/MA for
readmission tracking, $14/hr x
2hrs
Advanced practice provider @
$43/hr (8hrs/week for 12
weeks)
Pharmacist @ $58/hr x 2 hrs
Equipment/Materials
Tools for patient assessment
Thermometer $30.00
BP cuff $30.00
Bag $30.00
Stethoscope $ 80.00
Pulse oximeter $25.00
Cell phone to call patients for
12 weeks
Laptop for the project use
(documenting the home visit for
12 weeks)
Patient paper charts
Copying patient’s EMR for
paper chart
Pill cutter for each patient
@$5.00 X 12
Pill organizer @ $6.00 X 12
pts
BP machine @$30.00 for 12 pts
Digital weighing scale
@$25.00 X 12 pts
Education materials
$6/pt X 12 pts
Pulse oximeter $25 X 12pts

Expenses

In-Kind Support

$2184.00 (35%)

$4056.00 (65%)

$900.00
$28.00

$4128.00

$116.00
$195.00

$300.00
$600.00

$75.00
$50.00
$60.00
$72.00
$360.00
$300.00
$72.00
$300.00

APRN-LED TRANSITIONAL CARE PROGRAM
Gift cards for 12 patients
$300.00
($25.00 each)
Magnetic business cards (12)
$30.00
Office/Operations
Utilizing physician’s office and
$200.00
computer for checking the
EMR to identify patients 4
hours/week for 3 weeks
Utilizing physician’s office and
$200.00
computer for outcome data
collection
Total Expenses
$3968.00
$10558.00
A funding of $4,000 has been granted for this project from American Association of
Colleges of Nursing and the Centers for Disease Control and Prevention (AACN/CDC)
with support of the Academic Partners to Improve Health (APIH).

33

APRN-LED TRANSITIONAL CARE PROGRAM

34

Appendix J
Grant letter

June 14, 2016
5338 W Maldonado Rd
Laveen, AZ 85339

Dear Ms. Kala Sugathan:
We are pleased to inform you that your DNP Evidence-Based Population Health Project has been
recommended for funding by our expert advisory. The decision to award you this funding of $4,000 was made
after a careful review of your application materials.
Your proposal was awarded high scores. Congratulations on an excellent proposal!
To begin, we would like to publicize your award on our AACN Website and communications materials. If you
have any objections, please notify Ms. Allison Jacobs.
We ask you acknowledge the support of the Academic Partners to Improve Health (APIH) in any
publications. We can provide you with approved acknowledgement wording when needed.
Please note due to federal restrictions funding can only be dispersed in four equal quarterly payments after
receipt and acceptance of the required progress reports. Due dates for the quarterly reports are listed below and a
template for the reporting is attached to this email.
Quarterly Report/Funds Disbursement Dates: September 15, 2016
December 15, 2016 (Note: The second quarterly payment will be contingent on IRB
approval or documentation of exemption for the project.) March 15, 2017
June 17, 2017 (Final Report Due)
To advise us of your intentions, please email Ms. Allison Jacobs, CDC Project Manager, directly indicating your
acceptance or declination of this offer. Her email is ajacobs@aacn.nche.edu. In addition, she will be your
AACN point of contact during the project period. If you have additional questions, please do not hesitate to
contact her.
Thank you for your continued efforts in population health. Sincerely,

Joan Stanley, PhD, CRNP, FAAN Senior
Director of Education PolicyAmerican
Association of Colleges of Nursing

ADVANCING HIGHER EDUCATION IN NURSING
One Dupont Circle NW, Suite 530 ∙ Washington, DC 20036 ∙ 202-463-6930 tel ∙ 202-785-8320 fax
www.aacn.nche.edu

APRN-LED TRANSITIONAL CARE PROGRAM

35

Appendix K
Statistical Analysis
Table 2
Demographics
Percent
(%)
Age
Gender:
Female
Male
Race/Ethnicity:
African American
Asian
Caucasian
Hispanic or Latino
Native Hawaiian or Pacific
Islander
Other
Marital Status:
Married
Single
Divorced
Widow/widower
Living with partner
Employment status:
Employed
Unemployed
Retired
Highest level of education:
Less than high school
High school graduate
Technical school
Some College
College degree
Masters degree
Doctoral degree
Post graduate degree
Chronic conditions:
Heart Failure management:
Cardiologist
Primary care/Internal medicine
None

Frequencies Mean (SD)
79.14 (6.74)

71.4
28.6

5
2

0
0
100
0
0

0
0
7
0
0

0

0

57.1
14.3
0
28.6
0

4
1
0
2
0

0
0
100

0
0
7

0
28.6
0
28.6
28.6
0
14.3
0

0
2
0
2
2
0
1
0
2.00 (.58)

85.7
14.3
0

6
1
0

APRN-LED TRANSITIONAL CARE PROGRAM
Prescription medications:
Social support:
No
Yes
Current Housing:
House
Rent
Apartment
Group home
Homeless
Number of ER visits in the past six
months:
Number of hospitalizations in the
past six months:

36
10.71 (1.38)

0
100

0
7

71.4
0
28.6
0
0

5
0
2
0
0
1.00 (1.55)
.71(1.11)

Table 3
Readmission data

Readmission at 30 days
Readmission after 30 days
Direct admit

N
7
7
7

Mean score (SD)
.00 (.00)
.14 (.38)
.14 (.38)

Table 4
Pre and Post intervention QOL Score Results

Pre-Intervention
Post-Intervention

N
7
7

Mean score (SD)
49.29 (13.29)
29.71 (10.19)

Median score Range
51
32-72
27
18-43

Table 5
Pre and Post intervention SCB Score Results

Pre-Intervention
Post-Intervention

N
7
7

Mean score (SD)
25.43 (5.56)
14.29 (2.14)

Median score Range
24
17-34
14
12-17

N
7

Mean score (SD)
23.86 (.38)

Median score Range
24
23-24

Table 6
Satisfaction results

Satisfaction score

APRN-LED TRANSITIONAL CARE PROGRAM

Table 7
Friedman Test

N
Chi-Square
df
Significance

Test statistics
7
30.35
5
.000

Effect size (ES)
ES = Mean (posttest group) – Mean (pretest group) ÷SD (pretest group)
ES for MLHFQ = 29.71 – 49.29/ 13.29 = -1.4
ES for SCB = 14.29 – 25.43/ 5.56 = -2

37