Project Goal

M. KELLY QUALS GRANT PROPOSAL

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PROJECT GOAL To improve clinical outcomes and quality of life for Californians with chronic disease. OBJECTIVES • Expand the number of providers who effectively care for patients with chronic conditions. • Increase the participation of patients and families in all aspects of care. • Offer strategies for handling challenges, improving communications, and maximizing the benefits of family involvement in chronic illness care. PROJECT OUTCOME Twenty-five nurses in California will complete the Care Transitions online learning module. BACKGROUND Rising rates of chronic disease require new modalities of health care delivery in order to maximize quality of life and the health status of Californian’s. Chronic disease affects an individual’s level of functioning and their ability to care for him/herself and is associated with low quality of care. A client with a chronic disease such as hypertension may need to seek care from several sources, such as a community clinic, private physician’s office, or cardiologist (Anderson, 2007). One of the most vulnerable transitions between care settings is after hospital discharge, when a client is discharged home and they may feel under-prepared to manage on their own and lack an understanding of their medication (Coleman, 2006). Nurses are in a unique position to assist clients and their families with chronic disease management by developing clients’ ability for self-care, especially when transitioning between care settings. Coleman’s Care Transition (CT) model (2002) improves outcomes as clients’ transition between care settings as the model fosters self-reliance in chronic disease management. CT is a four-week program in which the nurse takes on a coaching role with the client after their hospital discharge. The nurse-coach builds a working partnership with the client which is defined by empowering clients and their families to safely manage their care. A transitions coach provides tools to clients so they can successfully keep a personal health record with a complete list of current medications, follow up with medical appointments after discharge and take the correct action if their condition worsens. The CT model provides nurses a focus in their practice to positively impact the quality of clients’ care as they move through multiple health care settings. The challenge of disseminating the CT model to practicing nurses in California requires innovation. This proposal will facilitate the creation of an online CT learning module that is user friendly and allows nurses enhance their awareness in preparing clients to transition between care settings safely. The project’s aim is to get 25 nurses in California to participate in the CT online learning module and explore results.

M. KELLY QUALS GRANT PROPOSAL

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PROJECT OBJECTIVES

TIMELINE 8/2009- 6/2010

1. Develop Care Transitions advisory group

August 2009

Recruit 8 nurses interested in Care Transitions

August August

Clarify roles and responsibilities, set meeting schedule Sponsor Webinar on Care Transitions for advisory members Reserve booth, meeting room & food at November CINHC conference Develop implementation plan with Care Transitions advisory group

August September 2. Create Care Transitions online module / tools

September

ACTIVITIES & APPROACHES

Design online module with IT consultant

September Recruit content experts & infuse input on module

3. Pilot test Care Transition online module in 25 nurses

October

Webinar- launch interactive CT tool

November 2nd

Care Transition online module at CINHC conference. Have booth set up for nurses* trial online tools with prepost test measures Analyze test results to ascertain if modules are effective in increasing knowledge of Care Transitions. Incorporate feedback, seek input from advisory group Create Care Transitions competency certification as professional development incentive 6-8 groups of nurses from various hospitals complete CT online module Evaluate comments and post test scores of participants Final comments from advisory group At CINHC conference disseminate Care Transitions module findings: how-who-outcome Write up lessons learned and components for sustainability

November 4th6th November 7th -20th

4. Further testing of Care Transitions online Module 5. Summarize findings

January 2010 February February March May

*Note: Participants will be practicing nurses who spend 25% of the professional role in direct patient care and no previous experience with formal Care Transitions programs.

M. KELLY QUALS GRANT PROPOSAL

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CARE TRANSITIONS ONLINE LEARNING MODULE California HealthCare Foundation BUDGET 50,000 USD Two conferences x 2985 each 5970. California Institute for Nursing & Health Care (CINHC) ************************************************* Staff & incentive costs 40030. ************************************************* Indirect costs 4000. Administration of funds 8% 4000_________ Total 50,000 AUDIENCE & STAKEHOLDERS Intended audiences for this project are practicing nurses in California who will benefit from the experience gained in the on-line learning activities in caring for clients across care settings. The stakeholders are clients and their families in various communities in the state, such as members of the public who pay for health care, and also various managed care and health maintenance organizations. Of particular interest in improving the outcomes of people with chronic disease are the government-based insurers such as MediCal and Medicare, both of which are developing re-imbursement schemes, which aim to save costs and prevent hospitalizations. DESIRED OUTCOME Engage nurses to infuse Care Transitions into their professional nursing roles and practice. As nurses become competent in transitioning clients with chronic disease safely between care settings, it may be possible to increase quality of life, and expand the capacity the clients’ self-care. EVALUATION & MEASUREMENT The project will be evaluated on the timely implementation of an online Care Transitions Interactive Module, which will be piloted by no fewer than 25 practicing nurses. Information on the participants experience with the module and post-test scores will be summarized and further recommendations made.