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Geriatric Nursing 34 (2013) 339e343

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GAPNA Section

Two GNPs create and innovate in anindependent house call practice

Debra Bakerjian, PhD, RN, FNP *,Phyllis J. Atkinson, RN, MS, GNP-BC, WCC

Kathy Ferriell, GNP and I, Phyllis Atkinson, GNP, were headed toSt. Louis for the Annual GAPNA conference in 2008. We had justeach seen our first House Call patient in our independent NP HouseCall Practice. After spending countless hours on starting the prac-tice our dream was finally a scary reality. Little did we know theflood gates would quickly open and the referrals soon made itpossible for us to both leave our secure NP positions.

The greatest challenge to seeing that first patient would soonprove to be a very positive outcome, the collaborating physician.Kathy had heard about a Geriatrician who had recently come to thelocal university and took the risk of reaching out and contactinghim. Not only was he interested, hewas excited. He understood andsupported the role of the NP and needed a clinical site for third yearmedical students to do a house call visit during their geriatricrotation; clearly a “win/win” for all involved. Not only was he goingto collaborate, but the other two Geriatricians in the practice werealso going to collaborate. In 2008, we began meeting weekly todiscuss complex/challenging cases. The “we” consisted of usuallyone collaborating MD and the two GNPs. The meeting quickly grewto include the geriatric fellow(s) andwewere soon charged to bringforth challenging cases for the fellow to solve. To date, our weeklymeetings have grown to be interdisciplinary and are currently partof a research project focusing on the care of dual eligibles. Theseweekly meetings now include a psychiatrist, several geriatricians,an internist, a family practice physician/researcher, a psychologist,a geriatric PharmD, a social worker, four NPs, geriatric fellows,family practice residents and medical students. For approximately90min, complexmedical/ethical cases are discussed as are complexgeriatric issues including such topics as competency, patient safety,medication compliance, as well as challenges faced by medicalproviders who provide care for older adults.

It is now mandatory for all third year medical students to makea house call visit, usually with the NP, which not only demonstratesthe role of the NP, but exposes the student to another model ofpractice. Their assignment includes medication review, gait/

* Corresponding author.E-mail address: debra.bakerjian@ucdmc.ucdavis.edu (D. Bakerjian).

0197-4572/$ e see front matter � 2013 Mosby, Inc. All rights reserved.http://dx.doi.org/10.1016/j.gerinurse.2013.06.008

balance assessment; reason for visit; IADLs, ADLs, GDS and MMSE.They are also asked to determine if the current living situation isappropriate and if the older adult will still be living in 6 monthsand, if still living, will it be in that same environment. These visitshave been very rewarding for many of the students as they recog-nize the need and complexity of a house call practice. One of ourfirst students is now completing her geriatric fellowship program.Another student had commented to the patient, a WWII prisoner ofwar, howhismother was a home health nurse and howas a child heuse to make visits with her. He was so excited to hear my patient’sstories, he asked if he could return with his wife, “just to visit.”

The family practice medical residents also spend a day with oneof the NPsmaking house calls. This has been valuable for the NP, thepatient and the resident. The resident is exposed to the role of anNP and the house call practice model. The patient always appreci-ates having a second opinion and appreciates the relationship toa University. The NP benefits from having a fresh set of eyes ona patient as well as educating a resident on the care of older adultsin the home. Another medical resident who spent time with us isnow completing his Geriatric Fellowship.

Since starting the business in 2008, it has expanded to over tencounties, 500 patients and five NPs. In October of 2012 the practicewas sold to a home health care company in an effort to bea comprehensive model that would be more valuable to managedcare companies in the reality of servicing the dual eligibles. Whileour name, logo andmission statement has changed, everything elsehas remained the same.

With our expansion, it was necessary to find another collabo-rating MD to cover another large metropolitan area. We were veryfortunate to find anMDwho had previously been faculty of a familyresidency program. She had contacted us to gain knowledge onhow to start a house call practice herself in a neighboringcommunity. Through that meeting she agreed to collaborate withus. The NPs that are in her area also meet face to face on a weeklybasis to discuss difficult cases. She is always willing to teach andshare ideas and she has also been willing to see our patients whenwe have had concerns.

We currently have two office administrators. One works fulltime and the other 4 days a week. Both work from their homes andhave assisted in the success of our practice. While our patients havenever met them, they smile at each visit as they talk about theconversation they had with them on the phone.

We also outsource our billing and our answering service. We allrotate call, answering our own calls Monday through Friday fromeight in the morning until six in the evening. The NP on call takescall from six in the evening on a Monday until eight in the morningthe following Monday.

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We have also explored other avenues to expand the role of NPscaring for older adults in the community, which included inservicesfor the home health care agencies on how to prevent rehospitali-zations. This has improved the communication between the NP andthe Home Health Nurse (HHN). Now the HHN will call when in thehome and there is a noted change in condition, hence reactingquickly and reducing hospitalizations. Kathy and I are also bothwound care certified, which has allowed us to market our woundcare services to home care agencies.

We have also been preceptors for NP students, one who is nowon staff with us. One acute care NP student admitted she was angryshe was told to spend time doing geriatric house call visits. She saidshe thought it was going to be so boring but was amazed at howmuch she learned and how complex older adults truly are, partic-ularly without the machines/monitors attached.

Five years ago, when we saw that first patient, I would havenever imagined our practice would have grown to the value/significance that it is today. It has not only touched my life inways Iwould have never imagined, but more importantly, it has touchedthe lives of all those we serve: the older adults, their loved ones, thehome health aides, the nurses and all the students who are gettingexposed to frail older adults.

Practice brief: A hydration initiative ina long-term care facility

Elizabeth M. Long, DNP, APRN, GNP-BC,Amber Rickenbrode, RN,Tammie Thibodeaux, CNA

Hydration among long-term care residents is a complex issue.Dehydration is listed as a citable condition during a facility surveyand is considered an indicator of Nursing Home Care Quality by theCenter for Medicare and Medicaid Services2. It is also identified asoneof the top litigationprone areas in long-termcare4. In aneffort tobe proactive, a local 120-bed long-term care facility enacted amulti-

Fig. 1. Phases of hyd

phased initiative to deal with potential issues of hydration withinthe facility. Fig. 1 depicts the phases of the hydration initiative.

As Fig.1 depicts, in the first phase of the initiative, the Director ofNurses (DON) and the facility Gerontological Nurse Practitioner(GNP) identified patients at risk for hydration related to theirfeeding status. The second phase encompassed a comprehensivehydration assessment of the identified patients by the GNP. Thethird phase involved implementation of a hydration team followedby periodic reassessment by the team of all identified patients. Thelast phase is currently in progress and involves identification ofadditional patients who might benefit from the program. Theseprocesses are explained in greater detail below.

1. Process

1.1. Phase I

During the first phase, residents with an altered feeding status,and thus potential issues with hydration, were targeted as potentialparticipants in the initiative. Residents were considered to havealtered feeding status if they met the following criteria; orders forfluid restriction, nothing by mouth (NPO) status, gastrostomy tube(GT) feedings, or on a modified liquid consistency. These consis-tencies included thin, honey, nectar, and pudding thick. The DONand GNP worked together to assure accurate identification of thesepatients utilizing the computerized ordering system and input fromthe floor staff and speech therapist. Thirty seven patients met theinclusion criteria.

1.2. Phase II

The second phase of the initiative involved the evaluation ofeach identified patient by the facility GNP developed a HydrationAssessment Form utilizing evidence-based information in theliterature1,3. The form is illustrated in Fig. 2 below. The Categorieson the Hydration Assessment Form included Co-morbid Condi-tions, Risk Factors, Medications, Labs, Physical Assessment, Addi-tional Comments and Recommendations. The GNP used the form to

ration initiative.

GAPNA Section / Geriatric Nursing 34 (2013) 339e343 341

guide the assessment. The formwas then completed to include theGNP’s recommendations and forwarded to each individual primaryhealth care provider.

Initially, 10 patients were identified with orders for fluidrestriction. Based upon findings by the nurse practitioner duringthe assessment and evaluation, it was recommended that 7 of the10 patients be taken off of fluid restriction. The seven identifiedpatients had previously been placed on fluid restriction related toa low sodium level. Upon assessment by the GNP, four patientscomplained of thirst, three patients had a dry and fissured tongue,and three had labwork indicating a normal sodium level within theprevious week. All primary care providers agreed with the GNPrecommendations of close assessment, repeat sodium levels in 1e2weeks, and removal of fluid restriction. In subsequent evaluations,the patients continued to maintain normal sodium levels and hadno signs of fluid overload. The three patients who remained on fluidrestriction had a medical contraindication for discontinuation(dialysis, and severe CHF).

Patients with NPO status were assessed closely for signs ofdehydration by the house GNP. All patients whowere NPOwere fedand hydrated via a gastrostomy tube. Recommendations from thefacility GNP varied from periodic lab work to reassessment by thespeech pathologist. During this phase of the initiative, patients ona modified liquid consistency were also evaluated for signs ofhydration issues.

1.3. Phase III

The third phase of the initiative involved the development ofa hydration team. This team consisted of the GNP, the DON, andthe hydration aide. Other interprofessional team members con-sulted based on assessment findings included the primary care

Fig. 2. Hydration As

provider, the speech therapist, the occupational therapist, and thedietician. Upon recommendation of the GNP, the hydration aideoffered a selection of appropriate fluids to each identified resident.Key to the success of the program has been determination ofwhich flavors of fluid the patient prefers. This has brought to lightthe need for a variety of fluids. Patients have identified fluids nottypically kept in house such as vegetable juice, pineapple juice,fruit nectar, and specific flavored sodas. A hydration cart wascreated which includes water, requested juices, and requestednectars, and appropriate thickeners or pre-made consistencies ofthe fluids.

The hydration aide maintains a hydration record on a separateHydration Record for each patient. The sheet contains the patientname, ordered fluid consistency and a space to record the amountand type of fluid consumed at each hydration pass. A hydration passis made once in between breakfast and lunch and once in betweenlunch and dinner. The hydration aide observes the patient consumetheir fluid and is allowed time to sit and visit to encourageconsumption of the fluid. The team has initiated other hydrationactivities such as a weekly happy hour, serving appropriate fluids.During this weekly time, the requested variety of sodas are servedas well as the usual fluids served from the hydration cart. Sodas arenot routinely served on hydration rounds.

1.4. Phase IV

The DON or the facility GNP reviews the Hydration Sheetsweekly. The hydration aide notifies the DON or NP of any issuesnoticed during hydration rounds. Weekly, the facility GNP reviewsthe computer database to determine if any additional patients havebeen placed on fluid restriction or any of the other identified risksfor hydration issues.

sessment Form.

GAPNA Section / Geriatric Nursing 34 (2013) 339e343342

1.5. Phase V

Currently the team is working toward identification andassessment of additional categories of residents who are potentiallyacutely at risk for hydration issues. These include residents with aninfection, pressure ulcer, or diagnosis such as dementia. Theprocess will be ongoing within the facility.

2. Discussion

This process originated in an effort to be proactive in identifyingpatients at potential risk for dehydration within our long-term carefacility. The interventions within this process have increased theamount of fluid the patients consume and staff awareness ofpatient’s hydration status. In addition, channels of communicationwithin the interdisciplinary team have improved with the use ofthe Hydration Assessment Form and Hydration Record. Theseforms provide important information to the primary care providerand surveyors in reviewing the facilities efforts to assure adequatehydration of our residents. During the recent survey, there were notags for hydration. Upon re-evaluation of the residents on theinitiative, by the nurse practitioner, none have been found to havesigns of dehydration.

As expected, the rate of urinary tract infection has decreasedsince the implementation of the hydration cart. We are alsocurrently investigating if the fall rate has decreased within thefacility with the implementation of this initiative. Most impor-tantly, patients throughout the facility, look forward to the passingof the hydration cart. Patients comment they look forward to thehydration pass as they get to choose what they would like to drink.This five phase process to improve hydration in our residents wasnot only successful in achieving the initial goals, but also improvedresident satisfaction and brought various members of the team towork together on this important initiative.

References

1. American Medical Directors Association. Dehydration and Fluid Maintenance inthe Long-term Care Setting. National Guideline. http://www.guidelines.gov;2009.

2. Center for Medicare and Medicaid Services. Nursing Home Quality Initiative.http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/index.html?redirect¼/nursinghomequalityinits/; 2013Accessed 09.05.13.

3. Thomas D, Cote TR, Lawhorne L, et al. Understanding clinical dehydration and itstreatment. J Am Med Dir Assoc 2008;9:292e301. http://dx.doi.org/10.1016/j.jamda.2008.04.006.

4. Weinberg A, Levine J. Clinical areas of liability: risk management concerns inlong-term care. Ann Long Term Care 2008;13(1):26e32.

Communication and nursing:Reflections of a broadcast journalistnurse

Carole Bartoo, MSN, RN

Every nurse is a communicator; someone who deciphersa bewildering array of medical and health care system informationinto plain language for patients and their families. But the changinghealth care system now requires us to findmore, and better ways toconnect with, and engage patients and families. One of the greatestcomplaints patients have about health care is that when they leave

clinic appointments or hospital stays, they often feel confusedabout what they should do next to manage their own care. Asa result, a popular topic of research today, especially in the area oftransitions of care, is examining the relationship between effectivecommunication and compliance.

My view of effective communications is shaped by a formercareer as broadcast journalist. In 15 years of work as an anchor/health reporter in Television markets including Columbus, Ohioand Nashville TN, my goals were to engage the public in develop-ments in medicine and science, provide empowering health infor-mation, and connect the audience with health care professionals.Nursing goals are similar.

I would like to share a few lessons and techniques learned in mycareer reporting on health topics for television, and in my currentrole in media relations for an academic medical center. I find theseitems to be useful in developing communication with patients. Ihope they might apply to health care providers in any disciplinewhen working to improve communications with patients e

particularly our elder patients and their families.First, in broadcasting, a key to operationalizing any techniques

used to focus a messagewithin any health report is to recognize theaudience is distracted. At 5 or 6:00 p.m., newscasters are keenlyaware are watching the newscast while fixing dinner or managingkids. Similarly clinicians know patients have busy and complicatedlives. We are aware that, especially if they are ill, patients andfamilies are distracted. Being mindful of this while preparing forgoal-oriented communication can be very helpful.

Second, most useful, hard-and-fast rule used in formulatinga news report which aims to capture and keep a distracted Tele-vision audience is the KISS principle: Keep it Simple, Stupid or ifyou prefer, Keep it Short and Simple. The KISS principle forces thecommunicator to use an “economy of words,” and use it well. Ibelieve this should be a major tenant of provider/patient interac-tions as well.

In media training here at our academic medical center, we helpour experts employ the KISS principle through use a tool calledSOCO (pronounced Sock’-Oh, like the knock-out punch): The SingleOverriding Communications Objective. SOCOwas developed by theCenters for Disease Control to help scientists prepare for mediainterviews regarding infectious disease outbreaks. The expert isasked to formulate one line to sum up the single most importantpiece of information they would like the story to convey. They areallowed to list three additional facts that go with this SOCO;however, the goal is to weave the single objective throughout theinterview. The effect is powerful control over the message, avoidingboth sidetracking, and confusing information overload. As someonewho has conducted thousands of interviews, I can tell you, a well-executed SOCO sounds neither robotic nor rehearsed; rather it isfocused and persuasive. I believe a similar tool would be of benefitto clinicians in preparing for patient interactions.

The third, and perhaps most important thing I learned as healthreporter is that the audience must be part of the conversation.Audience research found, time and time again that people listenmore intently to stories if they contain the perspectives of otherordinary people, like themselves. As a reporter, this meant that inorder to increase the chances that a message would be heard;a patient interview must absolutely be included and weighted asheavily in the balance of time as the expert’s interview. Whether ina very private and confidential setting, or through a public mediumlike television, people have much to say. As nurse practitioners, wecan benefit greatly from using the language and experiences of ourpatients, and even our personal experiences, and those of ourfriends and families. To do this effectively we must approach each

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communications opportunity with the intent of listening, andvaluing what every patient says in relation to their own care.

.It was a privilege inmy broadcast years, to be invited into privatehomes, where I had the rare opportunity of providing a forum forpeople to share their unique human experience. In the end, it wasa bright-lights-and-fancy-camera way of listening. Intervieweeshave told me talking through the media allows them to “do some-thing,” in situations in which they may have little control.

Today I find great joy in continuing to be invited into people’slives through nursing. I believe active efforts to engage, include,

and empower our patients in effective communications will bea key to improving quality of care. A personal goal within mynew role as an ANP is to become more involved in researchregarding care transitions and improved communications.

In the meantime, I will draw from these lessons learned: Usingthe KISS principle to develop a thoughtful and engaging SOCO. ThenI will put onmy old interviewer hat againe encouraging patients totell their own story in their own words. If I can do that, and thenlisten well; patients might just be more willing to hear what I haveto say.