Diane L. Spatz, PhD, RN-BC, FAAN, Helen M. Shearer Professor of Nutrition, University of Pennsylvania School of Nursing; Nurse Researcher - Lactation, Children's Hospital of Philadelphia

Background and Goal

The World Health Organization (WHO), as well as numerous other worldwide professional groups, recommend that infants are exclusively breastfed for the first six months. In 2014 in the United States, less than 19% of infants were exclusively breastfed for the first six months. WHO states that millions of infants continue to die from lack of access to human milk/breastfeeding. With the advent of lactation consultants in 1985, many nurses in the United States abdicated their former role as counselor to breastfeeding families. But the continuity of care nurses share with patients is significant and provides nurses with a unique opportunity to play a critical role in helping breastfeeding families achieve the recommended goal of exclusive breastfeeding for the first six months and continued breastfeeding for a year or more. 

To increase breastfeeding in the US, the current focus has been the implementation of the Baby Friendly Hospital Initiative (BFHI). Unfortunately, the BFHI designation neither addresses the needs of vulnerable infants nor includes NICU's as part of its process. The goal of 10 Steps to Promote & Protect Human Milk and Breastfeeding in Vulnerable Infants is to close the current gap in care that results in our most vulnerable infants, who start life in a NICU and are most in need of human milk, being the least likely to receive it at discharge.

Program Description

Dr. Spatz has developed a model of care that has been implemented in hospitals throughout the US and abroad (including all NICU's in Thailand) to educate health professionals on the best practices for the use of human milk and breastfeeding vulnerable infants. 

Dr. Spatz provides clinicians with the framework and tools to change practice and achieve measurable results that are personalized, convenient, cost-effective, and innovative. This program addresses the significant health disparity/lack of human milk and breastfeeding culture in the United States and around the world, as well as the critical role of nurse in lactation support. Dr. Spatz has developed training programs for health professionals on strategies for implementing the model.

Evidence of Success

• In 2000, prior to the implementation of Dr. Spatz's program, the percentage of NICU infants at Children's Hospital of Philadelphia (CHOP) receiving human milk at discharge was approximately 30%. Since 2008, because of the implementation of 10 Steps to Promote & Protect Human Milk and Breastfeeding in Vulnerable Infants, over 99% of mothers who deliver in the hospital's Special Delivery Unit initiate pumping for critically ill infants. In 2014, of infants born at CHOP and discharged from the NICU, over 86% were discharged on human milk.
• Furthermore, recent research at CHOP demonstrated that mothers of surgical NICU infant graduates breastfed on average for 8 months (range 0.25 to 30 months) and provide more exclusive human milk to their infants than both state and national statistics.
• Where there were previously no breastfeeding trained staff nurses, CHOP now has over 600 staff nurses trained to provide evidence-based lactation support and care so that mothers can reach their personal breastfeeding goals.

Patricia Gerrity, PhD, RN, FAAN, Executive Director, 11th Street Family Health Services; Associate Dean for Community Programs, Drexel University College of Nursing and Health Professions

Background and Goal

Poor and minority populations suffer from disparities in healthcare when compared to other populations. More than 46 million Americans lack health insurance, with 17million more “underinsured.” Minority populations suffer from a greater incidence of diseases such as diabetes and from related complications.

Eleventh Street Health Services goal is to work in partnership with the community to develop a healthy living center that is community-based and culturally relevant, providing not only access to clinical services but also to a wide-range of health promotion and disease prevention services to reduce health disparities in an underserved population.

Program Description

Eleventh Street Family Health Services, Drexel University is a Healthy Living Center operated by the College of Nursing &Health Professions that provides access to a broad trans-disciplinary team of health professionals with clinical services sustained through a partnership with the Family Practice & Counseling Network. It also has a strong educational and research component; serving as a clinical practice site for many students of the University and conducting research and documenting outcomes of the trans disciplinary approach to care. It provides comprehensive, trans-disciplinary care to residents of public housing communities and other vulnerable populations including 26,676 clinical service visits and1,676 home visits to pregnant or new mothers and 6,827 patient encounters in health education and wellness programs.

Evidence of Success

• Reduced pre-term births to 2.5% in African American women seen at 11th Street compared to 15.6% in Philadelphia (2011).
• Improved Quality of Life for patients participating in the fitness program, as measured by the SF 36, with a significant increase in perceived health status at 3, 6 and 12 month follow ups (2011).
• Decreased unnecessary medical specialty workups for children whose issues are family/behaviorally based, such as enuresis, through the integration of a pediatric behavioral health consultant in primary care.
• Increased the use of self-care plans for patients with chronic illness to 100% and increased patients’ self-efficacy through the Living with Chronic Illness Program (2010-2011).
• Recognized by the Pennsylvania Governor’s Chronic Care Collaborative as one of 3 state-wide practices with an innovative approach to lowering blood pressures in patients with serious diabetes.
• Replicated the Kaiser Permanente Adverse Childhood Events study with the 11th Street adult patient population, revalidating the role of childhood trauma and adversity in the development of health problems in adults. Used these data to plan relevant programs to address trauma (2010).
• Received a Healthy Workplace Award from the Philadelphia Business Journal for its efforts to provide time and opportunities for staff to participate in health promoting activities (2010 & 2011).
• Included as a case study in the IOM report on The Future of Nursing to illustrate community partnerships to reduce health disparities.
• Named on the Innovation Exchange of the federal Agency for Health Quality Research (AHQR) for opening access to care.
• Serves as a clinical practicum site undergraduate nursing, nurse practitioner, physical therapy, creative arts therapies programs and from Drexel’s School of Public Health.
• Received more than 20 million dollars in grant funding from federal agencies, private foundations and corporations since 1998 to build and support the 11th Street trans-disciplinary model of care.

María de los Ángeles Ortega (formerly Ordóñez), DNP, APRN, GNP-BC, PMHNP-BC, CDP, FAANP, FAAN, Director, Louis and Anne Green Memory and Wellness Center; Professor, Christine E. Lynn College of Nursing, Florida Atlantic University

Background and Goal

As the population ages, the number of people diagnosed with Alzheimer’s disease and related dementias (ADRD) rises. The current healthcare system is not equipped to adequately meet the needs of an aging diverse population. In particular, Latino and Haitian communities are often unable to access dementia-specific care. Many dementia-specific programs in place fail to provide support for Latino and Haitian families, who provide the majority of the care.

A literature review shows depression, stress, low self-efficacy, and knowledge deficit about Behavioral and Psychological Symptoms of Dementia to be consequences from prolonged caregiving. The Louis and Anne Green Memory and Wellness Center (MWC) has successfully implemented a nurse-driven, innovative, dementia-specific model to improve health and health equity through community engagement. This model represents a significant step towards achieving health equity among Latinos and Haitians living with ADRD in the United States. Building, cultivating, and sustaining authentic relationships and engaging with individuals as well as their communities are cornerstones of the MWC’s innovative and transformative approach.

The MWC seeks to expand access to care that is grounded in caring and to transform the support available to community-resident older adults as well as their caregivers. Since its inception, the MWC has integrated home-based and in-clinic services to optimize care and developed dementia-specific supportive services for persons living with Intellectual and Developmental Disabilities and ADRD, specifically those with Down Syndrome.

Program Description

The Louis and Anne Green Memory and Wellness Center (MWC) model embraces a transformative, holistic model of specialized dementia care and supportive services informed by nursing theories, perspectives, and caring science. Caring is a complex and multi-dimensional concept. The MWC model embodies an innovative way of caring science being translated into action. This nurse-led program addresses the complex needs of persons with or at risk for ADRD and their families, guided by what matters most to each person. This model is critical in advancing the health of persons living with ADRD as well as their family caregivers while improving health equity for the community and reducing costs of care.

The uniqueness of integrating mind, body, and spirit to deliver care that is individualized, convenient, cost-effective, and innovative is exemplified, practiced, and lived within this nurse-designed model. Specifics of the model include: 

• Nurse-driven program focused on memory and wellness evaluations, accurate diagnosis, risk reduction identification and care planning, delaying cognitive decline, increasing quality of life, and providing continuity of care and support for the person with ADRD and the family caregiver. Care provided collaboratively is led by gerontological nurse practitioners working with an interprofessional clinical team of experts, including psychiatric-mental health nurse practitioners, psychiatrists, neuropsychologists, social workers, and staff, each trained specifically in caring science, geriatrics, and gerontology.
• Guided by a caring-based conceptual nursing perspective framework.
• Transformative delivery of care through a biopsychosocial, and diverse, inclusive lens.
• Scholarly, culturally and linguistically responsive, person-family-community-centered, interprofessional practice and education approach.
• Integration of student clinical experiences and faculty practice ineffective delivery of dementia-specific health care, research, advocacy/policy, and community service.

Evidence of Success

The Caring Science Model of Specialized Dementia Care for TransformingPractice and Advancing Health Equity has been successful at increasing access to care among Latino and Haitian individuals with ADRD, and their caregivers, by:

• Using culturally-tailored interventions to reduce depression, anxiety, stress, and social isolation in older adults with ADRD;
• Transforming dementia care through embracing caring and technology during COVID-19 and beyond;
• Maintaining culturally appropriate services, technology, and supports for people living with dementia and caregivers during COVID-19;
• Partnering with faith-based communities to provide dementia-specific care and supportive services;
• Integrating Psychiatry and Mental Health Care within the caring-based model of dementia-specific care and supportive services, in-office, home-based, and virtually;
• Reducing perceived burden while increasing self-perceived competence among family caregivers to best fulfill their caregiver roles, while self-preserving and maintaining their best possible quality of life;
• Healthcare delivery model aligned with clinical outcomes of the MWC practice, where a healthy practice is achieved by integrating and aligning best practices including clinical, financial, and ethical protocols;
• Reduced healthcare costs for individuals and the healthcare system:unplanned hospitalizations, unnecessary re-admissions, and/or premature institutionalizations;
• Reduced overall burden of healthcare expenses of individuals and their families by allowing the caregiver to remain in the workforce longer through reducing stress, depression, anxiety, and other burdens and providing respite care, resources, services, and supports; and
• Increased quality of life experienced by individuals living with ADRD and their caregivers as well as satisfaction with caring-based programs and services.

The model has received more than $10 million in grant funding from state and federal agencies as well as private foundations and corporations. It has also received over $8 million in fee for services since 2014 to build, support, and expand the Louis and Anne Green Memory and Wellness Center Caring Science Model of Care. The model has been replicated by institutions and communities nationally and internationally. It also serves as an interprofessional clinical practicum site.

Billie Lynn Allard, MS, RN, FAAN, Administrative Director of Population Health and Clinical Ambulatory Services, Southwestern Vermont Medical Center

Background and Goal

The fee-for-service model of health care in the United States has created silos which cause medical errors, wastes resources, and duplicates efforts. With the transformation away from family physicians to specialists and hospitalists, patients often have 3 to 4 providers involved in their care. To address these issues, Billie Lynn Allard, MS, RN, led a nursing team at Southwestern Vermont Health Care in the development of a Transitional Care Nursing (TCN) program which utilized acute care clinical nurse specialists to facilitate care across the continuum for high-risk, high-cost patients.Following the implementation of the initial TCN, it became evident that a broader approach was necessary to truly impact the health of the community. What evolved is the creation of an Accountable Community of Health which employs multiple community sectors, reduces duplication in services, and shifts acute care resources across the community as part of an integrated care delivery system free to patients.

Program Description

The Accountable Community of Health model is a multifaceted care delivery system integrated into a broad spectrum of community programs designed to address the root causes impacting health and obtain optimal patient outcomes. A summary of these programs is set forth below:

• Transitional Care Nursing, in partnership with primary care providers identifies high risk patients with chronic disease, providing navigation, education on symptom identification and medication adherence while identifying gaps in care coordination.
• The Community Care Team consists of community partners who craft interdisciplinary shared care plans and facilitate collaborative care coordination for patients with substance use and mental health issues.
• Interventions to Reduce Acute Care Transfers (INTERACT™) empowers nursing assistants to utilize evidence based protocols to promptly identify changes in condition decreasing transfers to hospitals.
• Diabetes Care and Prevention is provided by Certified Diabetes Nurse Educators embedded in primary care offices, hospitals and skilled nursing facilities.
• Integrated Social Work gives a warm hand off of patients discharged from the hospital to Transitional Care SocialWorkers who assist patients to follow through with post discharge instructions and connect with resources.

Evidence of Success

Accountable Community of Health noted a 56.1% reduction in hospital admissions and observation status visits among high risk patients participating in the TCN program over 180 days, with a sustained decrease of 46.8% over a one year period. The Community Care Team demonstrated a 34.7% reduction in ED visit among patients with addiction and mental illness who frequented the ED when comparing 6 months before intervention and 6 months after (n=150 patients). A 12.4% reduction in A1C was achieved by patients working with a Certified Diabetes Educator within primary care practices. After the implementation of a pulmonary rehabilitation program, the 30 day readmission rate decreased from 17.26% to 2.56%.

Karen Cox, PhD, RN, FAAN, President, Chamberlain University

Susan R. Lacey, PhD, RN, FAAN, Associate Director Of Quality And Research at Society of Critical Care Medicine

Background and Goal

Traditionally, quality improvement projects are generated and diffused in a top-down approach and may or may not include staff nurses in the design of these programs, yet staff nurses are held accountable for the implementation and outcomes.

The American Association of Critical Care Nurses (AACN) Clinical SceneInvestigator (CSI) Academy (“AACN CSI Academy”) leverages staff nurses’ expertise to improve outcomes quality work by teaching staff nurses new skills in leadership, project management, and quality improvement methods. The program empowers and shepherds hospital-based staff nurses to lead an interdisciplinary team in the life-cycle of substantive quality initiatives that measurably improve patient outcomes and hospitals’ financials.

The curriculum and project outputs directly address three of the seven Institute of Medicine’s recommendations in the Future of Nursing Report:Recommendation 2-Expand opportunities for nurses to lead and diffuse collaborative improvement efforts; Recommendation 6-Ensure that nurses engage in lifelong learning; and Recommendation 7-Prepare and enable nurses to lead change to advance health. Similarly, the program advances the Institute for Healthcare Improvement’s Triple Aim by: 1) improving the patient experience of care (including quality and satisfaction); 2) improving the health of populations [particularly frail and vulnerable hospitalized populations], and3) reducing the per capita cost of health care.

Program Description

AACN CSI Academy aims to empower staff nurses with the knowledge and support necessary to become leaders who guide their peers in creating unit-based change that is easily scaled hospital-wide. The AACN CSI goals are accomplished through 8 experiential workshops led by AACN CSI national faculty over a 16 month period. In addition, hands-on coaching by hospital leadership provides the participants the knowledge of how to get things done in their respective organizations.

Hospitals select a team of up to four nurses from one nursing unit to work with AACN CSI Academy faculty to identify challenging issues, most frequently hospital acquired conditions (HACs). The content is delivered by the AACN CSI faculty in experiential learning environments, including onsite workshops, webinars and regular consultations in person, by phone and via email. At the end of the 16-month program the CSI teams present their projects and findings at a regionalInnovation Conference, hosted by AACN, for the community at large.

To facilitate the AACN CSI Academy’s commitment to share the results of these projects, the Innovation Database was launched in 2012. This is a searchable database that includes final presentations, project summaries, and toolkits that can be downloaded by anyone who accesses the site at www.aacn.org/csi. In addition, support from AACN staff is available to those who have questions about projects.

Evidence of Success

Consistent with its goals, the AACN CSI Academy has markedly improved clinical outcomes and improved the fiscal health of the participating organizations. Examples include:

• Franciscan St. Francis Hospital - falls were reduced by 70% over two years with an annual fiscal savings of $123,383;
• Riley Hospital for Children – the average ICU Length of Stay was reduced by .5 days for an annual fiscal savings of $4,154,500;
• Wishard Health Services – pressure ulcers were reduced by 64% over two years for an annual fiscal savings of$582,000.
• Duke Raleigh Hospital – average Length of Stay for vented patients reduced by 1 day; average length of Stay for surgical patients reduced by .7 days; total vent days reduced by 17%; Ventilator-Associated Pneumonia, pressure ulcers, and falls reduced to 0 over a six month period. Total annual fiscal savings of $1,241,962.

The following quotes from CNO's convey how the AACN CSI Academy program successfully demonstrates the value of the professional practice of nursing:

• "I've never heard nurses talk about 'fiscal impact' before. This MUST continue!"
• "...provided the nurses with a personal experience in the organization, positive excitement, and increased nurses' roles in research/quality - actually changed outcomes...brilliant program!"
• "Need to rekindle this culture for everyone. Someone believed in them."
• "Staff nurses are the key to building systems of quality. This program proves just that."

Sarah Rhoads, PhD, DNP, WHNP-BC, RNC-OB, APRN, FAAN, Professor, Chair, Department of Community and Population Health, University of Tennessee Health Science Center

Background and Goal

Most pregnant mothers expect to have a full-term pregnancy with a healthy baby to take home a day or two after delivery. When a neonate is delivered preterm or with a health condition that requires an extended hospital stay, it is difficult for mothers and fathers to remain at the hospital continuously and still maintain other family responsibilities, especially when parents live in remote or rural areas outside of an urban center. This often leaves the mother, the baby, or both far away from family and friends, which adds yet another level of stress on these families. Hospitalized infants frequently suffer delayed developmental milestones since they cannot hear the sounds of their mothers and other family members and NICU babies regularly suffer a stilted reentry into the family upon discharge from the hospital.

Dr. Sarah Rhoads redesigned and enhanced the Angel Eye Web-Camera System(Angel Eye) based on her research studies with the goal of helping mothers, fathers, and family members maintain a virtual presence in the NICU when they are unable to be physically with their hospitalized neonate.

Program Description

Angel Eye serves parents and families of neonates hospitalized in the neonatal intensive care unit (NICU) by using technology to improve communication and collaboration of families and providers. Angel Eye allows for a continual video feed from the neonate’s isolette/crib through a password protected, HIPAA-compliant website. Parents can decide which family members and friends can use the system and provide them with the log-on information.

The Angel Eye™ system provides its users two primary features: 1) one-way video of the hospitalized neonate transmitted virtually to the user and 2) one-way audio of the user as transmitted to the hospitalized neonate using an audio-controlled system that safely controls decibel levels. Also, for the first time in the NICU, Angel Eye has implemented a two way chat feature in which mothers and NICU nurses can communicate through the portal.

With these technological capabilities, parents and family members can talk, sing, or read to their neonate, while watching the reaction of their neonate from a distance. Angel Eye also empowers families to introduce siblings of the hospitalized neonate to promote family bonding.

Evidence of Success

From 2010 to 2015, 1023 families and over 2,600 individuals used Angel Eye to connect and communicate with their neonate at the University of Arkansas for Medical Sciences (UAMS). Dr. Rhoads successful innovation caught the eye of an investment capitalist and, in 2012, Angel Eye developed into a company. This opportunity resulted in the total number of Angel Eye camera systems increasing to 579 deployed throughout 28 hospitals in 14 states and 2 countries.

Enhanced parent communication such as provided through Angel Eye has been proven to decrease stress and anxiety in mothers and fathers. In addition, Angel Eye reduced the financial stress otherwise experienced by families of neonates in the NICU. Due to tremendous medical advances related to survival of the tiniest of babies, length of stay in the NICU has steadily increased. On average, a NICU stay is 20 days with an average cost of $3,000 per day (2010). The financial costs incurred by parents physically visiting their neonate 3 times a week during a 20 day period averages $2,039/couple for rural parents making the minimum wage ($7.90/hr.) and $5,079/couple for urban parents making the national average ($25.80/hr.) Angel Eye helps alleviate this hardship while enabling parents and family members to bond with their hospitalized neonate.

Claudia J. Beverly, PhD, RN, FAAN, Murphy Chair in Rural Aging Leadership and Policy, Donald W. Reynolds Institute on Aging, University of Arkansas for Medical Sciences

Danielle Altares Sarik, PhD,APRN, CPNP-PC, Director of Nursing Research and Evidence-Based Practice, Nicklaus Children's Hospital

Yui Matsuda, PhD, PHNA-BC, MPH, Associate Professor of Clinical, University of Miami School of Nursing and Health Studies

Background and Goal

The health care system identified a gap in support for patients discharged from the neonatal intensive care unit (NICU) and their caregivers during the transition from hospital to home care. Challenges during this acute transition period often led to readmission and increased care in the post-discharge period. To properly facilitate an optimal transition to home for patients and caregivers in this critical time, the Baby Steps model was conceptualized to connect the hospital system to the home for infants who receive NICU services as well as their caregivers.After studying the South Florida pediatric hospital, Nicklaus Children’s Hospital, the
Baby Steps model was conceptualized to serve those who face cultural as well as socioeconomic barriers in receiving equitable, quality, and stable access to medical health services. With the development of culturally appropriate and language concordant care, the Baby Step model aims to remove barriers to receiving care and provide support via a comprehensive, nurse-led approach after discharge.

Program Description

Nurses are instrumental in preparing individuals to make a smooth transition from the NICU to the home or a community setting. Recognizing the importance of clinical outcomes, financial burden, parenting self-efficacy, and access to care, the Baby Steps model uses telehealth as a method to connect trained NICU nurses to caregivers and infants in the acute transition period. Through telehealth, NICU nurses are able to assess the home environment, provide anticipatory guidance and health recommendations, act as liaisons to ensure access to specialized care, and provide information on evidence-based safety and Baby Steps services.

To ensure health equity, the model has implemented a loan system for those without access to a smart device. Additionally, the telehealth app is available in multiple languages, with bilingual NICU nurses and virtual interpreters available to allow all caregivers equal access to the model. All Baby Steps services are provided free of charge to limit financial barriers.

Baby Steps is available to infants and their adult caregivers who: 1) receive care in the NICU; 2) are discharged to a home setting in the community; and 3) reside within the state of Florida. Nurses through training and mock telehealth appointments are prepared to give anticipatory guidance, ranging from feeding recommendations, human milk and lactation support, safe sleeping environments and reduction of risks associated with sudden infant death syndrome to parental mental health and coping, and household safety.

Evidence of Success

After analyzing over three years of clinical data, the Baby Steps model has redesigned the process of receiving post-discharge care by ensuring access to language-concordant, culturally-competent, nurse-led telehealth transition of care services, regardless of insurance or socioeconomic status.

In the first three years of the program, Baby Steps has had close to 700 patients enrolled in the program, the majority of whom identified as Hispanic (55%) and accessed care through public health insurance (62%). Post-consult surveys demonstrate high satisfaction with the service, with 93% reporting the service was easy to use and 93% noting they were likely to recommend Baby Steps to others.

The program has also provided significant cost savings, with a total cost savings of over a million dollars estimated. By significantly decreasing 30-day readmissions, over $200,000 has been saved from avoidable readmissions alone.Additionally, analysis of caregiver data to capture savings for averted travel demonstrated that over 20,000 miles of travel were saved for families.

Baby Steps is aligned to health system value-based care initiatives, including the readmission reduction program, and decreases financial and travel burden for families as well as supports equitable access to care.
Funding for the implementation of the Baby Step model at the NicklausChildren's Hospital has come from grants, and currently the model is transitioning to a hallmark program that is included in the organizational operational budget.

Related Publications

"Baby Steps Program: Telehealth Nursing Simulation for Undergraduate Public Health Nursing Students" published in Clinical Simulation in Nursing (2022)

"A telehealth nursing intervention to improve the transition from the neonatal intensive care unit to home for infants & caregivers: Preliminary evaluation" published in Journal of Pediatric Nursing (2022)

"Baby Steps: Improving the Transition from Hospital to Home for Neonatal Patients and Caregivers Through a Nurse-Led Telehealth Program" chapter published in Worldwide Successful Pediatric Nurse-Led Models of Care (2023)

Cheryl Krause-Parello, PhD, RN, FAAN, Professor, Christine E. Lynn College of Nursing
Faculty Fellow, Institute for Healthy Aging and Lifespan Studies (I-HeAL); Director, C-P.A.W.W., Health Research Initiative for Veterans, Florida Atlantic University

Background and Goal

When Cheryl Krause-Parello, PhD, RN, FAAN arrived at the University of Colorado in 2013, there was no dedicated research initiative in the College of Nursing that focused on military veterans despite the large number of veterans and active-duty members and the high rate of veteran suicide across the United States. To address the health needs of veterans, Dr. Krause-Parello founded Canines Providing Assistance to Wounded Warriors (C-P.A.W.W.). C-P.A.W.W. focuses on how nurses and other healthcare providers may use the human-animal bond to provide quality care to veterans and their families across the United States. C-P.A.W.W.’s goal is to comprehensively advance interdisciplinary research, education, and practice protocols for wounded warriors and veterans.

Program Description

Risk factors related specifically to military service include depression, diminished internal locus of control, lack of resiliency, social disconnectedness and suicidal ideation, among others. An estimated 20 veterans die each day as a result of suicide. Animal-assisted intervention is a non-invasive, low-risk intervention to help alleviate these symptoms. Unlike prior animal-assisted interventions, which were based on subjective accounts and surveys from participants, C-P.A.W.W. employs scientific, objective scales of measurement which demonstrate how veterans benefit from animal presence and interaction. To accomplish its goals, C-P.A.W.W. builds community partnerships and investigates therapeutic canine interventions which positively influence health outcomes. The program emphasizes system planning, public policymaking, and thorough protocols of care development to deliver culturally congruent and competent care to veterans and military members.

Evidence of Success

One of C-P.A.W.W.’s current research projects demonstrates that when veterans with PTSD are provided a service dog, they are able to decrease or stop their psychotropic medications, thereby reducing undesirable side effects associated with these drugs. With the cost of treating PTSD in veterans skyrocketing in the past decade to $24,000 for a five-day inpatient hospitalization and $8500 a year for an average outpatient treatment, the cost to care for a service dog is approximately$4000 per year-80% less than a five-day hospitalization. In addition to significant cost savings, a C-PA.W.W. study which examined the effects of a facility dog on veterans receiving palliative care showed visits with the facility dog had a measurable impact on heart rate and salivary cortisol levels. Similarly, a C-P.A.W.W. study on active duty military being aeromedically evacuated from an air force base in Germany to the United States demonstrates that animal-assisted intervention reduces stress markers, providing non-pharmacological physiologic and psychological support for patients.

Carol J. Farran, DNSc, RN, FAAN, Rush College of Nursing

Background and Goal

Family caregivers of those suffering from Alzheimer’s Disease or related dementias are a vulnerable population because many are, themselves, advanced in age, are under stress and have a sedentary lifestyle – making them potentially more vulnerable to increased mortality rates.

Caregiver Skill Building Intervention aims to improve the mental and physical health of family caregivers using behavioral health promotion interventions from the Rush College of Nursing.

Program Description

Caregiver Skill Building Intervention (CSBI) is a nurse-led, research-based program that provides psycho-educational interventions to address family caregiver skill-building and increase caregivers’ physical activity. The research reflects a nursing perspective in its basic clinical approach to asking the question: “What do family caregivers need?” It provides interventions that integrate a variety of theoretical perspectives. The interventions initially were delivered in a group setting where caregivers benefited by learning skills in a supportive group environment. To accommodate stressed and sedentary caregivers’ individual needs, the program now provides a multi-component, individualized home-based intervention that addresses a combination of needs.

Evidence of Success

• Participants say the intervention helps them better deal with their care recipient and address their own stress. Caregivers who have been through the program are more likely to say: “it’s the disease,” and less likely to take the care recipient’s behavior personally. They also are more adept at reading their care recipient’s cues; a wife caregiver knew when to “back-off” when her husband said, “someone’s going to get hurt here.” (Farran, et al., 2004, 2007, 2008).
• Estimated to cost $375/per participant for five group sessions, assuming an average of seven participants per group.
• Care provided by family caregivers has been valued at $306 billion dollars per year (Arno, 2005). Interventions with family caregivers can result in cost savings for the family and society. Persons with depression have been found to have greater health care utilization, greater worker absenteeism and lower work productivity (Donohue & Pincus, 2007). Although most caregivers do not work outside their home, research has shown that “work-related savings” for low to moderate intensity interventions, similar to the CSBI, far exceed the $100-$400 spent when persons with depression receive such an intervention. (Wang, Simon & Kessler, 2008).

Jessica Anderson, DNP, CNM, WHNP, FACNM, UCHealth University of Colorado Hospital; UCHealth Highlands Ranch Hospital; Centura Longmont United Hospital

Background and Goal

The Center for Midwifery (CFM) at the University of Colorado College of Nursing provides access to comprehensive, person-centered, high-quality care across the Colorado front range. Within the United States, including Colorado where this model is based, there are notable challenges related maternity care access, including nurse-led midwifery care. Patients desiring the midwifery philosophy of maternity care have had to consider alternative options because of access challenges. The CFM model fills a need for access to certified nurse-midwives, evidence based, and care options to support patients in achieving their desired“birth wishes” for their care.

The CFM model was started in 2004 to serve the Aurora community but has expanded across the state of Colorado. The CFM model continues to identify additional opportunities in the state with the goal of expanding access to Coloradoans in areas where nurse-midwifery are is not easily accessible.

The CFM approach to care incorporates support, evidence, guidance, high touch care, and expert midwifery skills to patients of all ages. The practice provides a substantial portion of care to the pregnant population which focuses on the natural and healthy aspects of care. The goal is to provide a safe, satisfying experience that provides an opportunity of empowerment and a supported transition to parenthood.

Program Description

The Center for Midwifery (CFM) practice is a nurse-led model of care that focuses on comprehensive, person-centered, evidenced-based care. The CFM model has its own practice case load, focuses on health promotion, provides continuity of care throughout the lifespan, and has a robust referral network. In addition, the model focuses on providing a labor and birth experience that includes a variety of labor support options like hydrotherapy, water birth,
aromatherapy, nitrous oxide, and transcutaneous electrical nerve stimulation (TENS) unit application.

The practice encourages every pregnant patient to complete a “birth wishes” list that outlines what they envision for their labor and birth experience. The “birth wishes” centers the patient as the navigator of their care experience.

The CFM structure includes a core team of certified nurse-midwives (CNMs) who are dedicated to each specific practice location: CFM Lone Tree, CFM Anschutz Medical Campus or CFM Lone Tree. Each practice has a midwife lead to support the operation activities and is part of the larger University of Colorado College of Nursing midwifery leadership team. The midwives are full-scope and provide care in the inpatient and outpatient setting.

Evidence of Success

The Center for Midwifery model has contributed to outstanding outcomes within all the systems and hospitals where care is provided. As a result of the model, the University of Colorado Hospital was identified by US News and World report as #1 in Best Hospitals for Maternity Care in Colorado.

The CFM model has long-standing low rates of cesarean sections (11-13%), low episiotomy rate (≤ 1%), and successful VBAC rate (80%).

Financial stability is maintained through streamlined staffing, consistent ambulatory volumes, and accurate billing practices – submitting over $8 million in charges each year.

Sharon Schindler Rising, Founder & President Emeritus, Centering Healthcare Institute

Angie Truesdale, CEO, Centering Healthcare Institute

Background and Goal

Centering Healthcare Institute (CHI) is a nonprofit established in 2001 by SharonRising that aims to improve health by transforming care through Centering groups. The organization has worked closely with healthcare providers from all sectors to change healthcare. With over two decades of experience and innovation, CHI has become the go-to resource for group care. It has developed and sustained the Centering group model in more than 470 practice sites and within some of the largest health systems in the world.

Broad improvement in health care delivery requires engaging patients in their care and helping providers forge dynamic partnerships with patients. The Centering model of group health care aims to change the paradigm of health services to improve overall outcomes across the life cycle by providing education, training, and support for individuals and organizations in the United States and around the world.

Program Description

Centering is a model of group health care with three components – healthcare, interactive learning, and community building – provided in a group facilitated by a credentialed health provider and a co-facilitator who is a nurse or other appropriate staff member. The components are defined by several key elements that support the facilitated discussion. There are patient materials available for two of the established models: CenteringPregnancy and CenteringParenting, with potential for additional models in chronic care. CHI has a network of more than 12 consultants across the US who lead training workshops, provide consultation to sites, and conduct site approval visits. Centering groups are composed of a stable cohort of patients who meet regularly with their care provider for 90 minutes and up to two hours, which is ten times longer than in traditional prenatal care appointments. Centering promotes individual health empowerment and the opportunity for community-building. Visit www.centeringhealthcare.org for more details.

Evidence of Success

The Centering model has demonstrated repeated improved outcomes throughout 20 plus years of implementation and evaluation. Over 200 published articles, including three randomized trials, have reported improved health outcomes including up to a 47% reduction in preterm birth, better attendance, increased breast feeding, high satisfaction with care, longer pregnancy spacing and improved immunization rates. Cost studies are documenting significant savings to the system. In 2016 it is estimated that over 50,000 women in over 400 sites received care through the model. This model responds to the goals of the Triple Aim of Better Care, Better Health, Lower Cost.

In a randomized control trial conducted through Yale University on 1,047 women in public clinics randomized to traditional or group care, there was a 33 percent reduction in preterm birth for women in Centering groups. In addition, satisfaction with care was significantly higher; there were increased breast-feeding rates, and improved knowledge and readiness for birth and parenting. The University of Kentucky estimates that under their Centering Pregnancy Smiles program, a reduction in preterm births from 13.7 percent to 6.6 percent saved approximately $2.1 million over the two years of this study.

Deborah Gross, DNSc, RN, FAAN, Johns Hopkins School of Nursing

Susan Breitenstein, PhD, RN, FAAN, The Ohio State University College of Nursing

Christine Garvey, PhD, RN, Rush College of Nursing

Wrenetha Julion, PhD, MPH, RN, FAAN, Rush College of Nursing

Background and Goal

Most programs to enhance parenting skills and reduce behavior problems in young children are designed for white, middle-class parents – yet parents of color and those raising children in low-income neighborhoods may not share the same values or face the same child rearing challenges. Consequently, many parenting programs are not perceived as relevant or useful across different cultural and economic groups.

The Chicago Parent Program was created in partnership with African American and Latinx parents from different economic backgrounds to help strengthen parenting skills and effectively manage young children’s difficult behaviors. This evidence-based program is designed to help parents tailor effective parenting strategies to their goals and values.

Program Description

The Chicago Parent Program (CPP) is a 12-session parenting program, designed to reduce behavior problems in young children by strengthening parenting skills and confidence. In weekly meetings, a series of 157 videotaped vignettes of real parents and children filmed in various settings are used to stimulate discussion and problem-solving among a group of parents on how to manage difficult, real-life child behaviors. The CPP has been implemented in at least 19 states and the District of Columbia in schools, early childhood agencies, and mental health clinics.

Evidence of Success

• A randomized trial of seven day care centers serving low-income families in Chicago showed significant decreases in child behavior problems (based on parent and independent observer ratings) and parent reliance on corporal punishment. Effects were maintained up to one-year post-intervention.
• A randomized trial in Baltimore comparing CPP with another parenting program considered to be a gold standard demonstrated that CPP was equally as effective for reducing child behavior problems among children with a mental health diagnosis but cost about 50% less to deliver; parent satisfaction was also higher for CPP.

Nancy Donaldson, DNS, RN, FAAN

Diane Storer Brown, PhD, RN, FNAHQ, FAAN, Strategic Leader, Hospital Accreditation Programs, Kaiser Permanente Northern California Region

Background and Goal

The imperative for quality patient care has never been stronger. With nursing sensitive indicators and HCAHPS measures directly tied to reimbursement, in the midst of health care system reformation and transformation, the impact of nursing processes and outcomes have a direct effect on increasingly sensitive bottom lines for hospitals.

The Collaborative Alliance for Nursing Outcomes is leading the quest for global patient care excellence. Through participation in CALNOC’s nursing sensitive benchmarking registry, hospitals have consistently been able to translate their nursing quality data into actionable information to guide decisions for providing and improving patient care.

Program Description

The Collaborative Alliance for Nursing Outcomes (CALNOC) is a national non-profit corporation who has been on the forefront of providing research, information and services on nurse sensitive indicators since 1996 to its member hospitals. CALNOC contributed to the development of the National QualityForum (NQF) nurse sensitive metrics and is the measure developer for the NQFPressure Ulcer and Restraint Use prevalence measures for acute care. CALNOC’s data registry has aggregated over 51 quarters of data, representing more than1,741 patient units, over 64.5 million patient days, including 183,698 patient falls, and 534,345 patients evaluated for pressure ulcers and restraint use.CALNOC’s unique web-based reporting dashboard combines staffing variables overlaid with nurse sensitive patient care process and outcome indicators at the unit level to allow hospitals to aggregate and compare their data across units, divisions and, rolling it up to the hospital level, to benchmark with other like-sized institutions, systems, geographic regions, Magnet, and other relevant group designations. Using the CALNOC's customized reporting tools, staffing and other costs are lowered while patient care quality and safety are improved.

Evidence of Success

• Hospitals participating in the CALNOC data registry reported dramatic reductions in their Hospital Acquired Pressure Ulcer (HAPU) rates from 10% to 2.8% over the course of their benchmarking participation resulting in over $10M in savings.
• Half of CALNOC’s participating hospitals have achieved the Zero Target Objective in HAPU prevalence rates.
• CALNOC’s Medication Administration Accuracy Measure adoption is growing and research related to this innovative measure has confirmed the link between key safe practices and error reduction during medication administration.
• The CALNOC Team has sustained its ongoing and innovative research, publications and global collaboration for over 16 years.
  

Background and Goal

Ethiopia is the second most populous African country with a population of nearly 103 million. Within Ethiopia, Amhara is a regional state with nearly one-quarter of the country’s population and roughly 84% of Amhara residents living in rural communities. Within the region, nearly a quarter of the newborns are born with a low birth weight (LBW). Improving newborn and LBW survival is critically important for Ethiopia and East Africa.

Despite a 75% reduction in Ethiopia’s under-5 mortality from 1990-2016, the neonatal mortality reduction was less than half. And as under-5 mortality has decreased, newborn mortality has grown to account for over half of all deaths among Ethiopian children under 5 years old. In particular, LBW infants are much more susceptible to sepsis and mortality compared to their normal birth weight counterparts.

Program Description

KMC was formerly known as Kangaroo Mother Care when it was first developed in 1978. KMC is a feasible, high-impact and low-cost intervention for increasing survival among LMW infants. There is vast evidence to support KMC’s benefits for survival, yet fewer than 5% of eligible infants globally receive this type of care. The Collaborative KMC model uses transdisciplinary collaboration and co-creation strategies to expand access and use.

The Collaborative KMC model was designed, tested, implemented, and evaluated within Ethiopia’s health system to maximize sustainability and scalability. The model was optimized using one specialized, one general, and three primary hospitals in the Amhara region. It was developed collaboratively with the government health system and delivered by workers who were part of the health system, with inputs from the nurse-scientists research team. Further, biannual KMC performance review meetings in Amhara allowed front-line KMC nurses/clinicians, hospital leaders, implementation scientists, and regional government officials to jointly review KMC performance and co-create action strategies for increasing KMC. As a result of bi-directional learning, the AmharaRegional Health Bureau recruited additional nurses dedicated to KMC care.

Evidence of Success

The implementation of the Collaborative KMC model has resulted in high KMC coverage (63% of eligible infants at the population level), high KMC quality (16hours of SSC) and 87% overall survival among KMC-initiated infants. These population-level, clinically-relevant impacts are particularly notable when baseline provision of any KMC (regardless of quality) was <5% at baseline in the region.

According to the national government’s 2020/21 annual administrative performance report for the Amhara region, 62.4% of LBW newborns receivedKMC care.

In a costing manuscript commissioned by the World Health Organization, costs associated with the Collaborative KMC Care model were estimated and demonstrated. The Collaborative KMC model costs were 55.5% of NICU-based care.

Background and Goals

Health care systems have long expected nurses to independently care for medically and socially complex patients. The intricacy of this work does not allow time to engage meaningfully with patients, their social support systems, and their medical teams to address their complex needs. Missed opportunities across all aspects of care continue to trend upward, as do nursing turnover, nurse-patient ratios, and nursing burnout. Studies examining the association of nurse burnout to hospital outcomes have linked nurse exhaustion to higher rates of patient mortality, adverse events, and hospital-acquired conditions. 

Each of these major healthcare challenges impacts hospital systems, healthcare professionals, and all of the patients they serve. CommonSpirit Health (CSH) has not been immune to these challenges. The Virtually Integrated Care model emerged as an innovation to provide support to the bedside staff and to enhance communication with patients and their families. 

Program Description

The CommonSpirit Health Virtually Integrated Care (VIC) Professional Practice Model offers an advanced nursing professional practice model that addresses staffing, organizational, and patient outcome concerns by utilizing virtual technology to assist the bedside care team. In the VIC model, the virtual nurse is a fully integrated member of the health care team with leadership and clinical experience, working directly with the clinical nurse at the bedside, providers, pharmacy, ancillary services, and care managers to deliver patient and family centered care.

VIC uses “all in one” computer technology which is accessible through a touchscreen in the patient’s room. It allows for simple and quick access to the virtual nurse and language services. The Virtual Care Delivery Platform (VCDP) is present in each patient’s room and on an additional monitor at the nurse’s station. The VCDP is a proprietary software application designed in collaboration with nurses, information technology experts, and members of the bedside clinical team to allow for constant communication with bedside nurses through a secure chat feature in the electronic health record, and is able to access diagnostic test results, engage in quality and safety surveillance, and document nursing care for their co-assigned patients.  

The virtual nurse is co-assigned to a cohort of nurses each clinical shift, providing care and decision support for up to 24 patients during a day shift or 36 patients at night through six core roles: patient education, staff mentoring/education, real-time quality and patient safety surveillance, physician rounding, as well as admission and discharge activities. The virtual nurse elevates health literacy for patients through education throughout the hospital stay and in the discharge process. The VIC model ensures personalized patient care and leverages technology to enhance outcomes for patients as well as the nursing workforce by serving as mentors to clinical nurses at the bedside. 

Evidence of Success

Since the implementation of VIC in 2021 across the country with CommonSpirit Health, this professional nursing practice model has demonstrated significant clinical outcome improvements:

• On VIC units, hospital acquired pressure injuries have been decreased by 50-75% ; catheter associated urinary tract infections have decreased by 50%; and falls have decreased by 25%.
• Patient length of stay has also decreased 10-20% across all VIC units nationwide. Readmission rates have also improved.

Virtual RNs support decreased workload burden for nursing staff through decreased nurse interruptions throughout the clinical shift, leading to greater patient and staff satisfaction. VIC implementation has led to improved workforce satisfaction and cost savings:

• CommonSpirit Health has seen a 92% reduction in nurse turnover since VIC implementation, which equates to an estimated cost savings of over $1 million that would have been spent on nurse turnover. 
• Travel nurse usage across VIC units has decreased by 25-75% across the country, resulting in a $4.5 million savings per year across all VIC units. 

The Health Resources and Services Administration recognized the VIC model’s potential for addressing workforce shortages and provided funding for the pilot program in 2016. What started as a local CSH initiative, has since expanded regionally and nationally across CommonSpirit Health hospitals. By developing, piloting, and replicating VIC effectively, CSH has demonstrated this innovation as an effective nursing practice model for other health systems, key stakeholders, and policy makers to consider in addressing workforce shortages locally, regionally, and nationally.

Contact Information

Julie Tuel, MSN, RN, CCRN-CMC, SCRN, System Vice President Virtual Care Nursing Practice Transformation, julie.tuel@commonspirit.org

Additional Contributors

Linda Goodwin, MSN, MBA, NEA-BC, FACHE, System Senior Vice President, CNIO, Clinical Innovation, Virtual Care Transformation, CommonSpirit Health, Linda.Goodwin@commonspirit.org 

Kathy Sanford, Chief Nursing Executive, CommonSpirit Health 

Sarah Szanton, PhD, ANP, FAAN, Johns Hopkins School of Nursing

Background and Goal

Older adults’ independence and health is often compromised by chronic, age-related illnesses such as stroke, heart disease, arthritis and diabetes. The inability of older adults to successfully manage every-day life functions such as bathing, dressing, preparing food and taking medications increases the likelihood of their admission into expensive nursing homes. This is true despite research which confirms older adults are both healthier and happier when they are able to remain in their own homes.

Sarah Szanton, PhD, ANP, FAAN, working collaborating across disciplines with Laura Gitlin, PhD, designed an intervention, Community Aging in Place: Advancing Better Living for Elders (CAPABLE), to assist older adults in acquiring the skills, strength and necessary home modifications they need to support their independence.

Program Description

CAPABLE is a nurse-designed multidisciplinary (nursing, occupational therapy and handyman) intervention developed and tested to reduce health disparities among older adults and aimed at helping older adults “age in place.” By decreasing disability and improving physical function and self-care skills, Dr. Szanton and her colleagues reduce admissions to hospitals and nursing homes which would otherwise result from fall fractures, incorrect medication dosing and poor nutrition and diet.

Always proceeding from the vantage point of the older adult, CAPABLE’s nurse and occupational therapist assess each older adult’s mind, body and spirit to arrive at the goals which will enable that individual to age comfortably at home. This personalized and convenient intervention, conducted in the participants’ homes, is guided by the Society to CellsResilience framework published by Dr. Szanton and her colleague, Dr. Gill, in Advances in Nursing Science which posits that all humans are resilient at any age and are composed of multiple overlapping resilient systems.

Evidence of Success

In a population of low-income older adults on Medicaid and Medicare who participated in CAPABLE, 75% of participants improved their self-care over the course of five months, with the average CAPABLE participant cutting in half their disability (defined as the number of self-care tasks that are difficult to achieve). CAPABLE participants also experienced a decrease in their depressive symptoms similar to that of an anti-depressant medicine.

Comparing the health care cost expended for participants in CAPABLE to the health care cost for a non-participating group, CAPABLE saved, on average, $2,765 per quarter - or more than $10,000 per year – for Medicare for at least two years. Inclusive of all patient visits and home repairs and modifications, CAPABLE cost only $2,825 per year, with decreases in both inpatient and outpatient costs, fewer readmissions and fewer observation status stays.

CAPABLE is currently implemented in thirteen cities in eight states (including two rural areas) within a variety of policy settings from two Accountable Care Organizations, one hospital readmission project, a state Medicaid waiver of Home and Community Based Services, as well as in some free standing clinics.

Man Ping Wang, PhD, MPH, MPhil, BNurs, RN, FAAN, Principal Investigator, The University of Hong Kong School of Nursing

Background and Goal

Smoking, including second- and third-hand smoke, is the leading cause of death and disease burden worldwide. One-third of all smokers are located in China, yet Hong Kong has become a leader in tobacco control with just 10.2% of its population categorized as daily smokers, one of the lower smoking prevalence rates. Despite this, the remaining smoking population had substantially low confidence and intention to quit – from 80% to 30% in the past decade.

Nicotine is highly addictive. The unassisted quit rate is about 4-5%, but that can be doubled to 10% with appropriate behavioral supports and increase to as much as 30% with medications such as nicotine replacement therapy. Although smoking cessation treatment is one of the most cost-effective treatments for disease management, only very few smokers (about 20%) used smoking cessation services, even it is free of charge, in Hong Kong and many other countries.

Overall, current smoking cessation services need to be able to respond to the change in smoking epidemic, smoker characteristics, smoking and quitting behaviors, social inequalities, technologies and current and future pandemic in affecting access to services. A more agile, adaptive and scalable cessation service mode is needed. Based on long-term research on tobacco control and smoking cessation, this community-based smoking cessation service model has been established and the effectiveness has been vigorously evaluated in many large scale randomized controlled trials with results published in prestigious journals including Lancet Digital Health, JAMA Internal Medicine, Addiction andNicotine & Tobacco Research.

Program Description

The overall structure of the Community-based Smoking Cessation Program(CSCP) is to establish a research and practice platform to improve the smoking cessation services. The CSCP model consists of 4 key parts:

• Proactively approaching smokers for delivering opportunistic smoking cessation interventions;
• Developing brief, effective smoking cessation advices;
• Integrating effective components of smoking cessation service; and
• Promoting sustaining quitting using mobile phone information communication technologies (ICTs) for personalized behavioral support.

The overarching goals of CSCP are to:

1. Investigate new models of smoking cessation intervention; and
2. Improve the effectiveness and coverage of smoking cessation services.

In the past decade, this model has successfully identified effective intervention components including: brief smoking cessation advice; active referral of smokers to smoking cessation clinics; nicotine replacement therapy (NRT)sampling; financial incentive; real-time chat-based instant messaging support through mobile phones; and chatbot with artificial intelligence for improving motivation to seek help.

The CSCP model is an important platform to scale up the current smoking cessation services and is agile to continue its functioning during the pandemic period. CSCP is also a platform to develop and assess innovative cessation interventions and to build a critical mass of smoking cessation researchers for innovation sustainability.

Evidence of Success

Randomized controlled trials of the CSCP model have demonstrated the effectiveness on improving biochemically validated abstinence, increasing smoking reduction, quit attempt, intention to quit, smoking cessation services use, use of NRT, and reducing smoking relapse.

The model has been successfully integrated into current smoking cessation services to improve efficiency of smoking cessation services. Current smoking cessation services have used a proactive approach to recruit smokers in the community and workplace (e.g. smoking cessation mobile clinics). Brief advice model has been translated into practice for health care professionals in the community. Technology assisted interventions such as chat-based instant messaging support and chatbot are now used by service providers. Medication support (e.g. NRT) to help handling craving now have been mailed to smokers using sampling method developed by CSCP, particularly under the COVID-19 pandemic.

Smoking prevalence has been steadily decreased from 12.4% in 2000, 11.1% in 2010 and 10.2% in 2019. Lung cancer (age standardized, per 100,000 persons) incidence and mortality rates have declined from 34.1 and 26.5 in 2010 to 32.8 and 21.3 in 2019, respectively.

Connie Vance, EdD, RN, FAAN, Trustee, Hope for a Healthier Humanity; Professor, The College of New Rochelle School of Nursing

Mary Healey-Sedutto, MPA, PhD, Founder and Executive Director, Hope for a Healthier Humanity Foundation

Background and Goal

There are extremely high maternal and infant/child mortality and morbidity rates in Mexico, Latin America and the Caribbean, where families in remote, impoverished villages have no organized health care delivery.

It is necessary to provide information and basic skills that improve health practices in the community while empowering women, men and families to take charge of their health.

Program Description

Promotores de la Salud (PS) is a health education program developed and implemented by Hope for a Healthier Humanity (HHH) to prevent disease and promote health in poor countries devastated by major disease and illness such as indigenous regions in Honduras, El Salvador, Guatemala, Nicaragua, the Dominican Republic, Panama and Mexico. It is a course offered 2-3 times annually, with 20-30 participants per session. Participants are taught principles of case finding, teaching, counseling, basic health care, referral and social advocacy. Self-care for the promotores is discussed in an empowerment model that can then be shared with young people, friends and relatives. Topics include maternal and infant care, infectious diseases, acute and chronic physical and mental illness, family relationships and domestic violence.Trainees are provided textbooks, supplies and medications to supplement their work. Each trainee is given a comprehensive medical and dental examination as a teaching and role modeling tool. Participants are encouraged to share their experiences, perceptions, beliefs and aspirations about health, family and community issues.

Evidence of Success

• 90% of participants were teaching others in their communities; 100% were using the textbooks, supplies, and medication to more accurately assess and treat a variety of health conditions and illnesses; and 100% were able to treat medical emergencies, infections, accidents, and chronic illnesses with greater accuracy.

Lauran Hardin, MSN, CNL, FNAP, FAAN, Chief Integration Officer, HC2 Strategies

Background and Goal

High frequency and complex patients struggle with the silos that exist in the payment system and in the specialized healthcare delivery system. The complexity of their health problems and/or psychosocial needs make them high utilizers of Emergency Departments (ED) and inpatient services. As the Robert Wood Johnson Foundation reports, 5% of the population uses 60% of all healthcare resource dollars. Success in population health and a shift to ACOs require a robust strategy for high frequency/high cost patients.

The Complex Care Center began in February 2012 as a quality improvement and safety initiative for high frequency and complex patients in the ClinicallyIntegrated Network at Mercy Health Saint Mary's in Grand Rapids, MI, part of the Trinity Health system. A Model of intervention was created to stabilize complex patients by mentoring and maximizing existing resources in their circle of care. Building a community of consistency and safety around the complex patient population has been one of the key drivers of the change in outcomes.Linking providers in a shared plan of care decreases fragmentation and establishes a solid foundation. Addressing social determinants of health(housing, transportation, financial barriers, or mental health/trauma) as part of the shared plan adds to the foundation.

The Complex Care Center’s ‘population approach’ for high frequency and complex patients is an innovative nursing model of care coordination that operates as a facilitator and change agent, rather than a new case manager, clinic, or revenue source. The Center is focused on changing the system, rather than primarily trying to change the patient, and occurs whether the patient engages or not. The approach is inherently interdisciplinary and creates collaboration across systems and disciplines, rather than displacement, to improve patient outcomes.

In addition to patient intervention, the Center provides three other services to extend the effect: business intelligence, process improvement and population intervention. Annual reporting on the high frequency population (regardless of payer) including potential root cause drivers and subpopulations with financial impact is provided for the ClinicallyIntegrated Network.

Program Description

The five key aspects of the Complex Care Center’s model include: 1) a 10 year analysis of the medical record to capture the full patient story and identify root causes of frequency/complexity, 2) conferences for care management providers across the continuum of care (regardless of health system affiliation), 3) a shared evidence based plan (Complex Care Map) to change system response 4) embedding the plan in the medical record, 4) following the patient on every admission, and 5)readdressing the plan in iterations. Once referred, patients are followed for life and the Center re-engages the process as needed on every subsequent admission and emergency visit.

The Complex Care Center links providers into a community of support around the patient. Using a tool built into the Electronic Health Record to house the shared plan, an alert pops up the first time a provider opens the record for each ED or Inpatient visit, increasing the consistency of the care. Included in the process are reminders to hospital staff to link with the cross continuum team members managing the patient outside of the hospital, which reinforces the community of support around the patient. When the Complex Care Center’s analysis reveals a patient has ties with resources in the community other than with his or her primary care provider, the Complex Care Center facilitates formal relationships with these agencies to collaborate in the overall care and well-being of the patient. Complex Care Maps have rolled out to 25Hospitals in the Trinity Health system and are in the process of being implemented as a standard of best practice care for all EDs in Trinity Health (92 hospitals, 22 States).

Evidence of Success

• Population of 661 Complex Care Center patients for 12 months out from initial intervention experienced the following changes in access to the healthcare system:
  • 34% decrease in inpatient/observation admission
  • 26% decrease in length of stay
  • 35% decrease in ED/urgent care visits
• The decrease in loss from unreimbursed care from Complex Care Center patients in FY 2015 was $492,728 for inpatients and $1,145,885 for outpatients.
• Total direct expenses attributed to the same population of 661 Complex Care Center patients 12 months out from initial intervention decreased from $7.1 million pre-intervention to $4.2 million post-intervention.
• Total operating margin attributed to the same population of 661 Complex Care Center patients 12 months out from initial intervention improved $773,000

This project was undertaken as a Clinical Quality Improvement Initiative at Mercy Health, and as such was not formally supervised by the Mercy Health Institutional Review Board per their policies.

Margaret Grey, DrPh, RN, FAAN, Dean and Annie Goodrich Professor, Yale University

Background and Goal

Young people who suffer from type 1 diabetes – and their parents – need help dealing with the special challenges of that disease. Coping skills also are needed by youths at risk for type 2 diabetes (30-40 percent of new cases of diabetes in youth are type 2, which used to be a disease of the elderly).

Coping Skills Training assures that targeted youths – those of middle school age– have better metabolic control, quality of life, self-efficacy and coping skills than those who have received conventional diabetes education.

Program Description

Coping Skills Training is a cognitive behavior intervention designed and delivered originally by nurses and other health professionals in small groups, building on the standard of care in diabetes education. The focus is on improving the coping skills of social problem-solving, communication skills, stress management, and cognitive behavioral modification. The ultimate goal is to improve peer, school, and family relationships and enhance self-management. The program focuses particularly on youths in their early teens, helping to assure that negative behaviors are addressed before extensive damage is done to the child’s health. Current efforts have translated the program to a web-based format with graphic novel videos to illustrate skills.

Evidence of Success

• Youths with type 1 diabetes had much better physical and mental health - such that, if sustained, would result in a 25% reduction in long-term complications, at a savings of millions of dollars (2000). 
• Diabetes prevention participants demonstrated trends in lower glucose and insulin levels. Health behavior outcomes showed trends toward better choices of foods, resulting in reduced risk of diabetes development (2009).
• Parents and grandparents of targeted youths demonstrated improvements in overall health behaviors, including healthier nutrition choices, improved stress management skills, increased physical activity, and improved interpersonal relations (2009). 
• The web-based version of Coping Skills Training (TEENCOPE™) reaches 85-90% of youth (age 11-14 years, 72% White) and results in high satisfaction and participation.

Bernadette Mazurek Melnyk, PhD, RN, APRN-CNP, FAANP, FNAP, FAAN, The Ohio State University

Background and Goal

Each year, more than a half million infants (i.e., one out of every eight) are born prematurely in the United States. Preterm birth results in extended stays in the neonatal intensive care unit (NICU), developmental delays, physical and mental health/behavioral problems, increased medical utilization and poor academic performance. Preterm births cost the United States $26.2 billion annually.Parents of preterm infants experience a higher incidence of depression and anxiety disorders along with altered parent-infant interactions and overprotective parenting, which negatively impacts their children.

The Creating Opportunities for Parent Empowerment (COPE) program provides education and skills building activities to parents of preterm infants, in an effort to reduce hospital stays, enhance parent-infant interaction, and reduce parental depression and anxiety.

Program Description

COPE is an educational-behavioral skills-building intervention with informational CDs and a workbook that teaches parents about the appearance and behavioral characteristics of premature infants. The activities show the parents how to help meet their child’s needs, enhance the quality of parent-child interaction and facilitate their infant’s development, as well as help the parents implement the educational information.

Parents listen to educational information on 10-20 minute CDs as they read it in their workbook, providing corresponding skill-building activities that parents complete after listening. Successive interventions are delivered to parents 2-4 days after the infant is admitted to the NICU, 2-4 days after the first intervention, 1-4 days prior to the infant’s discharge from the NICU and, finally, about one week after discharge.

Evidence of Success

• Infants in the COPE program had a 3.8-day shorter hospital length of stay (mean of 35.2 days) than infants in the attention control group (mean of 39.2 days); an 8 day shorter length of stay for infants less than 32 weeks gestation.
• Overall, the program achieved cost savings of at least $4,864 per infant. For infants weighing less than 1,500 grams, net cost savings were $9,864 per infant. Translated to a national level, this means that delivering the COPE program in NICUs across the United States could save the health care system a minimum of more than $2 billion per year in addition to improving parent and child outcomes.
• Insurers and neonatal intensive care units across the U.S. and globe are adopting and implementing COPE and achieving even shorter hospital stays for their premature infants than was demonstrated in the original full-scale clinical trial.
  

Bernadette Mazurek Melnyk, PhD, RN, APRN-CNP, FAANP, FNAP, FAAN, The Ohio State University

Background and Goal

One out of four children, teens, and college-aged youth suffer from a mental health problem, such as depression or anxiety, yet less than 25% receive any treatment. This is largely due to an inadequate number of mental health providers. Untreated depression is the number one cause of suicide, the second leading cause of death in 10- to 34-year olds. Although the United States Preventive Services Task Force recommends screening all teens 12- to 18-years of age for depression, most providers do not screen because they do not have systems in place to manage treatment.

COPE is an innovative solution to address the high prevalence of child and adolescent anxiety and depression. It is the first known manualized intervention program that incorporates the key concepts from cognitive-based therapy (CBT)into a 7-session skills building program that can be delivered in brief 25 to 30 minute sessions.

Program Description

COPE is a variety of evidence-based CBT-based manualized intervention programs aimed at decreasing anxiety and depression as well as increasing healthy lifestyle behaviors and preventing overweight/obesity in children, teens, and college-aged youth. The COPE model consists of a 7-session brief CBT-based program delivered in 25-30 minute sessions by a variety of healthcare providers in primary care, school settings, and community-based mental health clinics.

Additionally, the COPE Health Lifestyles TEEN (Thinking, Emotions, Exercise, and Nutrition) Program is a manualized 15-session CBT-based program that can be integrated into middle and high school educational curriculum.

Evidence of Success

• Both the 7- and 15-session COPE programs are now being heavily used in school curriculums and primary care settings with reimbursement across the U.S. in 44 states and five countries, including Canada, the United Kingdom, Australia, South Africa, and Lebanon.
• The National Cancer Institute (NCI) has designated the COPE Health Lifestyles TEEN Program as a research tested intervention program as an obesity control intervention program for adolescents.
• Reimbursement to primary care providers delivering the 7-session COPE program equals $763. The average cost of a primary mental health hospitalization for a child or teen is $15,430. If 10,000 children/teens were hospitalized for depression, it would cost the healthcare system $154.3 million dollars. If hospitalization is prevented for those 10,000 children/teens by using the COPE 7-session program, the cost savings to the healthcare system would be $146.7 million.
  

Antonia M. Villaruel, PhD, RN, FAAN, Dean & Professor, University of Pennsylvania School of Nursing

Loretta Sweet Jemmott, PhD, RN, FAAN, Professor & Principal Investigator, University of Pennsylvania School of Nursing

Background and Goals

Young latinos begin sexual intercourse later than African-Americans or whites, but studies show Latinos use condoms less frequently. Lack of access to culturally and linguistically appropriate preventive services contribute to low condom use among Latinos.

The nurse-developed ¡Cuídate! curriculum for sexual risk reduction attempts to influence attitudes, behavioral and normative beliefs, and self-efficacy regarding sexual risk-reduction behaviors - specifically abstinence and correct condom use.

Program Description

The program emphasizes the Latino cultural beliefs of familialism and gender-role expectations, including machismo. These beliefs are used to frame abstinence and condom use as culturally accepted and effective ways to prevent unplanned pregnancy and sexually transmitted disease, including HIV/AIDS. It works to build HIV knowledge, increase understanding of vulnerability to HIV infection, identify attitudes and beliefs about HIV and safe sex, and increase self-efficacy for correct condom use, negotiating abstinence, and negotiating safer sex practices.

Evidence of Success

• The curriculum was designed to be implemented by a wide range of persons - including nurses, teachers, and community health workers. With the exception of salaries for trained facilitators and time for training, program costs are minimal.
• A simulated economic analysis of sexual risk reduction programs, including ¡Cuídate!, indicated that evidence-based programs designed to encourage safer sexual behavior provide a substantial benefit-cost ratio (about $2.50 for every dollar spent) and is an efficient policy in reducing teen pregnancy. 
• In an initial evaluation of 553 Latino youth who participated in the program in Philadelphia between 2000 and 2003, researchers found that youth who participated in the ¡Cuídate! intervention were:
  • 34% less likely to report sexual intercourse
  • 47% less likely to report multiple partners
  • 91% more likely to use condoms consistently
• The curriculum is included in the CDC's Diffusion of Evidence Based Interventions designed to bring science-based, community, group, and individual-level HIV prevention interventions to community-based service providers and state and local health departments.
• In FY 2010, the Department of Health and Human Services identified ¡Cuídate! as one of several nationwide programs that are effective in preventing teen pregnancy. Therefore, communities are eligible for federal funding to support further dissemination under the President's Teen Pregnancy Prevention Initiative.

Jacqueline Campbell, PhD, RN, FAAN, Professor & Anna D. Wolf Chair, Johns Hopkins University School of Nursing

Background and Goal

Domestic violence is a major cause of mortality for women in the United States.According to the CDC, homicide is the second leading cause of death for young African American Women, the third leading cause of death for AmericanIndian/Native Alaskan women aged 15-34, and the fifth leading cause of death for white women aged 30-34. When women are murdered, they are most often(40-54%) killed by a husband, boyfriend or ex-husband or partner. In 70% of the cases when women have been killed, there has been prior physical domestic violence. For every one woman killed by her partner or ex-partner, approximately 8-9 are nearly killed by their partner or ex-partner with serious long term health problems resulting. Campbell’s national intimate partner femicide study found that 40-47% of women who were killed were in the healthcare system (emergency department, primary care, prenatal care, mental health) in the year before they were killed. The goal of the Danger Assessment: An Instrument to Help Abused Women Assess Their Risk of Homicide (Danger Assessment or DA) is to assist abused women, domestic violence advocates, justice system domestic violence experts, and domestic violence policy experts to more accurately assess the risk of homicide from an abuser and obtain appropriate health care and other domestic violence safety planning interventions.

Program Description

Jacquelyn Campbell, PhD, RN, FAAN created the Danger Assessment in 1985. Prior to the DA’s creation, there were several non-evidence based, non-validated lists of warning signs of potential lethality in domestic violence situations. The wording of the Danger Assessment is based on research and was developed in collaboration with abused women.

Once the Danger Assessment is completed with an abused woman, it is scored by an advocate or health care professional as one of four levels of danger: Variable, Increased, Severe, and Extreme. The results of the DA are conveyed to the woman and measures are taken to obtain appropriate health care and other domestic violence safety planning interventions. The weighted scoring has been assessed at accurately capturing 90% of the cases of intimate partner femicide under the receiver operating characteristic (ROC) curve. Included in the Danger Assessment is a calendar which is innovatively applied to aid in recall, identify old injuries that may have been inadequately treated, and identify patterns of increasing severity and/or frequency of abuse victims are often unaware of which indicate increased risk. The calendar also serves as a useful evidentiary tool in court proceedings to document the frequency and severity of the abuse.

Evidence of Success

The Danger Assessment is used by domestic violence advocates and health care professionals in every state except Mississippi and Idaho, as well as in seven foreign countries (Canada, Mexico, New Zealand, Australia, Portugal, United Kingdom, South Africa) and, in 2018, is being launched in Brazil and Zambia. Approximately 1000 persons from multiple disciplines have been certified to use the Danger Assessment each year through either in person training (about 70% of
those trained) or through online training (www.dangerassessment.com). All nurses providing home visitation during the perinatal period with the Nurse Family Partnership home visitation program are trained in using the Danger Assessment.

A bench card on the DA has been developed for judges to use the DA in judicial training on domestic violence. The Danger Assessment may be taught to agencies in person for $1500 - $2500 or an in house trainer model may be used by the agencies to do its own training of new employees. A short user friendly form of the DA (Lethality Screen) has been created for use by police officers as part of a program (Lethality Assessment Program or LAP) which enables police offers to tell abuse victims if they are at high risk on the Lethality Screen and to immediately invite them to speak with a domestic violence advocate on the officer’s phone. The LAP is being used in 30 states in multiple jurisdictions in each of the states with support from the Department of Justice for community training.

Julia Gamble, MPH, NP, RN

Donna Biederman, DrPH, MN, RN, CPH, FAAN

Sally Wilson, MDiv

Background and Goal

People experiencing homelessness have high rates of physical and mental illness, increased mortality, and often repeated emergency department visits and hospitalizations. Homelessness exacerbates health problems, complicates treatment, and disrupts continuity of care. Frequently, people experiencing homelessness are discharged from hospitals with care instructions that are difficult to follow while living on the streets or in shelters.

Since hospitals are often reluctant to knowingly release patients into homelessness, some patients remain hospitalized beyond their expected date of discharge, thus increasing costs significantly. The Durham Homeless CareTransitions (DHCT) model addresses the disconnect between health and homelessness systems by providing a place for healing and an opportunity to stabilize housing, health benefits, and relationships with supportive services.

Program Description

Durham Homeless Care Transitions, establishes a pathway for safely discharging persons experiencing homelessness from an acute care setting.The hospital can consult with the transition team regarding their patients and receive expert advice and the opportunity to plan for a safe discharge. Patients who do not meet hospital inpatient criteria, but who are too ill sick or injured to stay in a shelter or on the streets, are offered placements in medical respite locations where they can safely recover and connect with services.

The DHCT model combines the medical respite stay with case management focused on connections to medical care (primary and specialty when appropriate), mental health and substance abuse treatment, acquisition of benefits, linkage to improved housing circumstances and connections to social supports. DHCT is the first health organization in Durham, NC to obtain funding from the local health department for medical respite housing to allow people experiencing homelessness a safe environment for healing and recovery from illness and injury. DHCT is the first health organization in Durham to obtain funding from the city to provide federally funded rapid rehousing services.During the COVID-19 pandemic, we have been the referral point for our three community hospitals and our community shelter for homeless individuals withCOVID-19 needing isolation housing assistance funded by our city and county.

Serving homeless people in transition from hospital to community, bridging the hospital and housing systems, and creating connections for our homeless patients to ongoing services are core tenants of the DHCT model.

Evidence of Success

Persons who participated in DHCT had a greater reduction in charges from the year prior compared to the year after referral (53% versus 27%). Program participants also had a greater percentage charge capture during the same time period (55% versus 30%). Our recent analysis demonstrated significant decreases in ED visits, admissions, and bed days for program participants in the year after the program compared to the year before.

A recent outcome analysis of 125 patients who had completed DHCT revealed that 78% were discharged to an improved housing arrangement, 88% had enhanced accessibility to transportation, 77% were reconnected with family or friends, 55% obtained or maintained substance use disorder treatment, 62%obtained or maintained mental health treatment, 90% obtained or maintained specialty care treatment, and 96% obtained or maintained a primary care medical home. This same analysis demonstrated “DHCT participants had lower average counts of hospital admissions (1.63 vs .62), bed days (16.37 vs 5.41),and emergency department visits (3.25 vs 1.71)” (Biederman et al.). After DHCT involvement, more previously homeless people are housed and achieve a number of positive outcomes which benefit the entire community.

Patricia C. Dykes PhD, MA, RN, FAAN, FACMI

Ann Hurley, DNSc FAAN, FGSA

Diane Carroll, PhD, RN, FAAN, FAHA, FESC

Background and Goal

Patient falls in acute care hospitals is a longstanding, persistent, and sometimes lethal problem. Falls are a major public health problem globally, and hospitalization increases the risk for falls. In the United States, falls occur in approximately 2-3% of hospital stays, and up to 1 million hospitalized patients fall annually. Fall rates range from 1.3 to 8.9 falls per 1,000 patient days with approximately 30% of falls resulting in injury.

Common fall-related injuries associated with morbidity and mortality include fractures, subdural hematomas, and excessive bleeding. It is estimated that falls with related injuries add 6.3 days to the hospital stay drive up costs.

Over 90% of falls in hospitals are preventable; accidental falls account for 14%and anticipated physiological falls account for 78%. Accidental falls include slips and trips caused by environmental factors such as food or liquid spills, environmental clutter, or improper footwear. Accidental falls can be prevented using "universal fall precautions" – those actions taken by nurses and other hospital staff to keep the environment safe for all patients. Anticipated physiological falls are caused by known physical factors and secondary effects of treatment. These fall risk factors can be predicted using a validated fall risk screening tool such as the Morse Fall Scale (MFS) and prevented when tailored interventions to address these specific risk factors are accurately and consistently carried out by all stakeholders. Physiological risk factors for falls include gait instability, lower limb weakness, urinary incontinence/frequency, need for assisted toileting, previous fall history, agitation/confusion or impaired judgment, and medication side effects.

Unlike other adverse events in acute hospital settings that may be prevented by implementing a standard checklist for all patients, fall prevention plans need to be tailored to individual patients based on their personal risk factors. Evidence suggests that one of the root causes of patient falls is poor communication of the fall prevention plan and failure of staff, patients and families to consistently follow the plan. To maximize communication, patient and family engagement should be integrated into each step of the fall prevention process and the fall prevention plan should be available at the bedside, not simply stored in the electronic health record.

Program Description

The Fall Tailoring Interventions for Patient Safety (Fall TIPS) toolkit makes the fall prevention plan operational. Our goal was to integrate patient engagement into the three-step fall prevention process (properly assessing for fall risk factors; developing a personalized fall prevention plan; consistently implementing the evidence-based plan) seamlessly into nursing workflow.

To address assessment, the Fall TIPS model uses the MFS which, when used properly, addresses all six common predictors of physiological falls. The TIPS model includes Clinical Decision Support in the Electronic Health Record (EHR)to automatically link each MFS risk factor to evidence-based recommendations that are feasible in hospital settings. As nurses complete the MFS in the EHR, an evidence-based plan is generated to address each risk factor.

In a series of clinical trials involving over 40,000 patients, the Fall TIPS Toolkit was associated with a significant decrease in falls and fall-related injuries. The toolkit includes a suite of tools to promote adoption and spread of evidence-based fall prevention best practices. It is currently used in over 250 hospitals and supported by over a decade of research.

Evidence of Success

The Fall TIPS program has demonstrated a 25% reduction in patient falls and 34% reduction in fall-related injuries. The JAMA 2010 study was the first randomized trial that demonstrated a significant reduction in patient falls in acute hospital settings. A systematic review of inpatient fall prevention programs gave the Fall TIPS study their highest quality score reflecting its rigorous design (cluster randomized clinical trial), large number of patients(n=10,264), and the fact that it was conducted in multiple hospitals.

Using a total sample of 1,242,895 patients and over 74 months of data, we categorized fall severity to understand how different degrees of fall-related injury impact costs. For the first time in over a decade, we calculated the cost of a patient fall in the hospital and the cost of associated injuries. These findings are currently under review for publication.

The Fall TIPS approach ensures that all risk factors are addressed and that scarce nursing resources are not used to unnecessarily implement interventions that will not mitigate risk. Nurses reported that efficiencies in patient care compensated for the time spent on the Fall TIPS program. Fall TIPS saved nurses’ time and supported engaging with patient and family in the fall prevention process.

Ruth Watson Lubic, EdD, RN, CNM, FAAN, FACNM, Founder, Family Health and Birth Center

Background and Goal

Low-income mothers are more likely to experience pre-term births, low birth weight babies and cesarean sections – all of which can lead to other medical complications and increase health care costs. These also are the major precursors to infant mortality. At an infant mortality rate of 10.84 deaths per 1,000 live births, Washington, DC, has the only double-digit infant mortality rate of any jurisdiction in the U.S.

We are a developing families center meeting the primary health care, social service and child development needs of under served individuals and childbearing and child rearing families through a collaborative that builds on their strengths and promotes their empowerment.

Program Description

The Family Health and Birth Center (FHBC) now integrated with the Developing Families Center provides a midwifery/nurse practitioner model for alternative, cost effective maternal/child care for low-income women. With the intent to replicate a birth center but with an expanded emphasis on social supports and early childhood education and redefining “perinatal” to include the time from preconception through the children’s 2nd year of life, the founder, a midwifery/nurse practitioner, established the FHBC in a low-income community in Washington, DC in 1994. The vision of the birth center was broadened in 2000 to include comprehensive social supports, case management, and early childhood education.

Evidence of Success

• After six years of operation, there was a substantial lowering of African American preterm birth (5% at the center vs. 15.6% of African Americans in DC), low birth weight (3% at the center vs. 14.5% in DC), and cesarean section rates (10% vs. 31.5% in DC).
• The center's successes in 2006 alone reduced costs for the District of Columbia's health care system by more than $1.6 million - more than the total of the center's annual operating budget.
• Breast feeding rates were also high at 88.4% at discharge and 56.8% at 6 weeks.
• Of 4 million U.S. births annually, 1.75 million are Medicaid-supported. Application of the FHBC model to all Medicaid births could yield a savings of almost $2 billion.
• Preliminary data for 2009 indicates the center delivered a record number of infants – more than 280 – as well as the highest absolute number – 59 – ever delivered outside the hospital in the District of Columbia (21 percent of births took place at the facility, with the remainder at Washington Hospital Center attended by Family Health and Birth Center nurse-midwives).
• Women cared for at the FHBC in the Developing Families Center have fewer c-sections, less assisted deliveries, lower rates of electronic fetal monitoring, more weekend deliveries (proxy suggesting fewer inductions/Csections), are more likely to go to 40 weeks or more.
• Care at DFC leads to fewer interventions, lower costs, and equivalent or better outcomes for the women receiving prenatal care at the center, most of whom are low-income.

Donna L. Torrisi, MSN, CRNP, Network Executive Director

Background and Goal

Public housing residents often are exposed to violence. As a result, they suffer trauma, post-traumatic stress disorder (PTSD) and many other physical and mental health issues. Furthermore, many public housing residents have problems accessing primary health care.

Family Practice and Counseling Network brings care directly to public housing residents in a cost-effective manner that fosters better care through nurse-managed clinics comprised of an inter-disciplinary health team that has been trained to address public housing residents’ special needs.

Program Description

Family Practice and Counseling Network (FPNC) is a system of three nurse-run health centers located in or near public housing communities in Philadelphia.They are based on a “one-stop shopping” model where patients receive care –seeing a behavioral health therapist, podiatrist, optometrist, dentist all on the same day. Prescriptions can be filled at the pharmacy or dispensary and patients can be transported to and from the health center via the health center van. There is a special $4 prescription fee for uninsured patients. Centers are accessible by means of location, ease of appointment, acceptance of all patients regardless of ability to pay and by creating a warm, inviting and friendly atmosphere. The primary care visit is charged on a sliding scale, based on federal poverty guidelines for patients who are uninsured, and lab work is included in that fee.

Evidence of Success

In 2011:

• Received $500,000 HRSA Award to open a new site in York, PA to serve public housing residents. Only 2 awards were given in PA and 60 in the country.
• FPCN was accepted into the state Phase 2 collaborative aimed to improve chronic and preventive care outcomes. It is a three year initiative.
• FPCN was subcontracted to provide services through a state grant called PA Cure Grant. The grant is a three year initiative that will be studying the effects of drug and alcohol screening, treatment, and referral in a primary care setting.
• FPCN was awarded a PEW grant to place Peer Specialists in health centers to improve the mental and physical health of patients with serious mental and physical health problems. A Peer Specialist is someone with lived experience with metal illness who acts as a coach and mentor to their patients.
• FPCN has demonstrated their capacity to manage the fiscal operation and has realized a surplus in all but one of its nineteen years. This year’s surplus is 1.1 million dollars.

2009 Clinical Outcomes:

• 70% of pregnant patients received prenatal care in the first trimester
• 85% of children age two were fully immunized
• 63% of Diabetic patients had HbA1c under 9
• In 2009, 98% of Diabetic patients were taking renal protective medication (ACE or ARB) and 100 % had self management plans and had received smoking cessation/reduction counseling

Financial Outcomes:

• Number of patients grew from 6,391 in 2005 to 14, 645 in 2009
• Number of visits in all disciplines increased from 30,254 in 2005 to 66,453 in 2009 and is projected to reach 75,000 in FY 2011
• Prescriptions filled grew from 5,800 in 2007 to 11,964 in 2009. Center pharmacies under the 340B federal drug program allowed the health center to shift from spending $70,000 for medications for uninsured patients to gaining a surplus of $70,000 from insured patients – money which then was used to purchase drugs for uninsured patients.

Angela Clark, PhD, RN, FAAN, FAHA

Cathie Guzzetta, PhD, RN, FAAN

Background and Goal

Families encounter it every day in ICUs and emergency rooms nationwide -- a critically ill or injured patient is wheeled in one direction while frightened family are shuffled away to await word of their loved one’s fate. It is one of the unwritten rules of critical care and emergency medicine that family members are not allowed in the patient’s room during emergency procedures. Providers base this rule on traditional concerns that families will be traumatized by the event, lose emotional control, and interrupt patient care.

The goal of Family Presence During Invasive Procedures and Cardiopulmonary Resuscitation (Family Presence) is to study outcomes of family presence on family members, healthcare providers (nurses and physicians), and patients. Encompassed within this goal is the mentoring of nurse colleagues in the research process, including presentation and publication of findings.

Program Description

Beginning in the mid-1990’s, Drs. Guzzetta and Clark designed instruments and studies to measure attitudes, perceptions, and outcomes of the family presence phenomenon at various adult and pediatric institutions. The key conclusion of these studies document that patient care is not interrupted. Findings provide evidence about the benefits for family members: removing family doubt about the patient’s situation and seeing everything possible was done; reducing their anxiety and fear about what was happening to their loved one; maintaining the family unit and need to be together. In addition, if death occurred, families reported that their presence gave them a sense of closure and facilitated the grief process.

From this work, they developed national guidelines for critical care and emergency nursing to provide nurses with the model and processes by which to implement family presence programs nationwide.

Evidence of Success

Consumers are powerful in changing practice when providers encounter resistance from within. Reports of our study results appeared in major newspapers and magazines such as US News & World Report, Newsweek, Redbook, Time, USA Today, The Washington Post, and The New York Times, Chicago Tribune, and American Medical News. Findings were disseminated on all major television news stations, reaching an estimated total audience of 8,636,000. The Parkland study received in-depth coverage on Good Morning America, NBC Dateline, ABC World News Tonight, and CNN. Radio broadcasts across the U.S. reached more than 10,000 stations. Numerous internet sites also carried the study findings to the public (e.g., ABC News.com, USAToday.com, Yahoo.com, CNN.com, WEBMD.com, HEALTHSCOUT.com, and REUTERSHEALTH.com). In addition, over 40 publications and presentations from this duo have shared findings of the work. Consultation to numerous institutions and other researchers has guided nurses to change the existing paradigm.

Background and Goal

Adolescent sexual and reproductive health (SRH) is a pressing public health and social welfare priority in the United States. Negative SRH outcomes represent a major source of morbidity among adolescents, both historically and presently, and expenditures associated with teen pregnancies, sexually transmitted infections (STIs), and HIV cost U.S. taxpayers billions of dollars annually.

Although significant progress has been made in reducing teen pregnancy rates in the U.S., the rates remain significantly higher than in other developed countries. Annually, there are approximately 160,000 children born to mothers younger than 20 years old. STIs pose another concern, with diagnosis rates repeatedly recording new all-time highs in the past decade. Youth aged 15–24years are disproportionately impacted by STIs—accounting for nearly half of the more than 26 million annual new cases of STIs, while representing only a quarter of the sexually active population. In addition, youth (13–24) account for approximately 20% of estimated new HIV infections in the U.S.

Health and social welfare costs associated with unplanned teen pregnancies,STIs, and HIV among adolescents represent a sizable financial burden on U.S.taxpayers. For instance, the annual federal and state cost of teen childbearing in the U.S. has been estimated at $9.4 billion. Furthermore, estimates suggest that lifetime medical costs associated with incident STIs among youth total $4.2billion. Each new HIV infection alone has been estimated to accumulate more than $400,000 in lifetime medical costs, and approximately 7,000 youth are estimated to be newly infected with HIV each year.

Further, alarming adolescent SRH disparities exist. Data suggests that Latino and Black adolescents have birth rates that nearly double that of the national average. Additionally, Latino and Black adolescents account for approximately half of reported STI cases and 8 in 10 new HIV diagnoses among adolescents under age 20. These figures point to a pressing need for innovative and efficacious models of care to promote SRH among adolescents in historically underserved communities.

Program Description

Traditionally, interventions designed to improve adolescent SRH outcomes have focused directly on adolescents through school-based curricula, social media campaigns, and community-based programs. Despite evidence supporting the importance of parental influences on adolescent decision-making, interventions that incorporate the family in preventing adolescent risk behavior are scarce.Families Talking Together (FTT) is unique in this regard, as it focuses on parents as the primary influence in prevention of adolescent sexual risk behavior, unplanned pregnancies, and STIs.

The FTT intervention consists of:

• Face-to-face intervention sessions (in-person or remote) between a parent and an interventionist;
• Printed FTT intervention materials for parents;
• Printed materials for parents to share with adolescents; and
• Homework exercises assigned to parents, such as practicing communication about sexual health with their adolescent.

FTT can be delivered to parents individually, in group sessions, and in a range of settings (health clinics, schools, community-based organizations, households, etc.). The FTT Clinic adaptation specifically designed for delivery in adolescent primary care settings formally integrates healthcare providers (HCPs) into theFTT model, thereby adopting a triadic (HCP-parent-adolescent partnership)approach to SRH promotion. FTT was adapted in linguistically (English and Spanish) and culturally tailored versions for implementation with Latino andBlack families.

Evidence of Success

FTT is effective in utilizing parental influences for adolescent SRH promotion and has resulted in numerous positive adolescent outcomes that reduce the risk of unplanned teen pregnancy, STIs, and HIV, including:

• Delayed sexual debut;
• Increased adolescent condom use;
• Reduced frequency of sexual activity;
• Increased parent-adolescent communication about sex;
• Improved parental monitoring and supervision; and
• High quality parent-adolescent relationships.

Estimates suggest that publicly funded programs for the prevention of unplanned pregnancies and family planning resulted in $13.6 billion net public sector savings. These SRH prevention programs were cost effective, as they resulted in $7 savings for each dollar spent on program implementation.

FTT is currently being implemented across the U.S., with a range of organizations from health departments to community-based organizations adopting the program to promote adolescent SRH locally. FTT has also been recognized as an effective program by the U.S. Department of Health and Human Services (HHS) and highlighted in a consensus study report by the National Academies of Sciences, Engineering, and Medicine (NASEM) as well as an evidence review by the U.S. Preventive Services Task Force (USPSTF).

FTT has received coverage in national media outlets, including NPR’s Latino USA.

Deborah B. Reed, PhD, MSPH, RN, FAAOHN, FAAN, Professor, Distinguished Service Professor and Good Samaritan Endowed Chair, University of Kentucky College of Nursing

Background and Goal

The health of farmers in the United States is in crisis. The responsibility of producing much of the world’s food rests with the approximately 12 million farm workers whose average age is 58. Many of the current farm operators are lifelong farmers who grew up working on their family farms and who will continue to work until their failing health forces them from their labor. The physical intensity of farming has left this population with a myriad of chronic health issues in excess of that experienced by the general population which include arthritis, hearing loss, hypertension, skin cancer, cataracts, and musculoskeletal disorders. Farmers are also at excessive risk for nonfatal and fatal injuries compared to other occupations, with senior farmers age 50 and over having a fourfold risk of dying from their injuries. As they age, farmers are also at higher risk for suicide. Over 97% of America’s farms are still family owned and operated and are exempt fromOSHA regulations; therefore, all attempts to implement health and safety precautions are dependent upon the farm families themselves. The goal of Farm Dinner Theatre is to take real life farm experiences and turn them into plays to raise senior farmers’ awareness of the many health challenges they confront and changes they can make to improve their health and safety.

Program Description

Dr. Deborah Reed, PhD, MSPH, RN, FAAOHN, FAAN designed Farm Dinner Theatre as a novel and effective method of moving the social norms of farm communities to adopt and embrace behavior changes which improve the health and well-being of older farmers and their families. Farm Dinner Theatre is a partnership between the University of Kentucky’s College of Nursing, the University of Alabama Institute for Social Science, Cooperative Extension programs in Kentucky,Tennessee, and Virginia, and local agricultural communities. Since Dr. Reed understood that senior farmers often resist approaching health care systems, she created Farm Dinner Theatre to be a safe environment where, over a meal and through truthful, humorous stories, members of a local farm community may share conversations about sensitive topics. Each dinner theatre is personalized for the location, with an extension agent enlisting local farmers as the planning group. The planning group supplies the real life stories and topics to be discussed, recruits the farmers to be the readers on stage, and manages the local financial and logistical support. The stories and topics are given to a nurse facilitator who turns them into scripts for three short plays which portray the cultural, physical, and spiritual struggles of farming.

The focus of each play is the meaning behind the story, not the acting or choreography. Between each play, the nurse facilitator leads a focused discussion so the audience can reflect on and personalize the story and its consequences. This discussion supports the farmers and their families in verbalizing possible solutions for the challenges identified in the play.

Evidence of Success

At both two weeks and two months after the theatre intervention, telephone interviews are conducted to assess the extent to which participants have thought about, talked about, or done something about the safety and health issues addressed in the plays. An analysis conducted with eight theatre and nine comparison sites (with comparison sites receiving a standard packet of 12 educational materials on the main topic included in the theatre) revealed that the theatre group increased their actions on health and safety more than the comparison group at both the two week period(Theatre- 57%; Comparison -40%) and the two month period (Theatre -60%; Comparison-52%). Moreover, at the two week and two month 24% and 38% of Farm Dinner Theatre attendees, respectively, shared their new knowledge with non-attendees. Ninety-six percent of the participants completed all aspects of the study. Dr. Reed was appointed to serve asKentucky’s Agriculture Nurse and now works across disciplines to develop and deliver health and safety programs forKentucky’s 85,000 plus farmers. She administers a Facebook page, AgNURSE (www.facebook.com/Agriculture.nurse) that reaches not only farmers, but health care providers who often do not understand or know about farmers’ health issues.

Betty Long, MHA, RN, President/CEO & Founder, Guardian Nurses Healthcare Advocates

Rebecca Rivkin-Czarkowski, MSN, RN, Vice President of ProfessionalPractice, Guardian Nurses Healthcare Advocates

Background and Goal

Poor communication and uncoordinated care continue to limit the quality of patient and family experiences in our healthcare system. Uncoordinated care impacts patient safety, clinical outcomes, cost of care, and patient engagement.Studies from the Agency for Healthcare Research and Quality (AHRQ) found that as more providers get involved in the patient experience, more coordination issues arise, increasing the potential for patients to receive conflicting information and for tests and procedures to be repeated.

Guardian Nurses’ Mobile Care Coordinator® (MCC) program was created as a win-win for patients and the union or employer that pays for their healthcare and that of their families. The program improves clinical outcomes for patients, thereby significantly lowering healthcare costs.

Program Description

The Guardian Nurses MCC program is nurse-centric and built on establishing a trusting relationship early in the patient’s healthcare journey. The program has proven that in-person contact from a nurse results in higher, lasting patient engagement than telephonic outreach. The unique MCC model triggers a nurse visit when a patient is admitted to a hospital. The nurse establishes a caring human connection and follows up with the patient to ensure a good experience and the best possible outcome.

Depending on patient needs, MCC nurses visit patients in their homes, expedite provider appointments, accompany patients to provider office visits, ensure needed tests and procedures are completed, procure needed resources, and coordinate communication and treatment plans with providers and the patient/family.

If the union or employer program is large enough to have multiple MCC nurses, one or more may be focused on complex care. If a patient has complex health issues requiring management, the program’s acute care coordinator may transfer the patient to a complex care coordinator

Evidence of Success

In a recent independent analysis of the program’s three largest clients, the model is associated with 31% lower total cost of care for engaged members vs. members who are not engaged. The program reduced readmissions among participants, which resulted in a cost savings estimate of about $1,722,000 or an average of $861,000 per year.

The model is also sustainable – as demonstrated by its expansion to the current 17 programs in multiple states with varied union and employer clients.

The Guardian Nurses’ Mobile Care Coordinator® program improves both clinical outcomes and health equity by providing high-touch, personal care coordination and patient advocacy to covered employees, union members, and their families. When the experienced registered nurses build trusting relationships with patients as they help them navigate the complex healthcare system, they also lower hospital admission and readmission rates through education and early intervention.

Background and Goal

Health disparities, low health literacy, and poor access to health care as well as relevant health education decrease the overall well being of residents. Disparities are worsened by severe economic resources, language and cultural barriers experienced by the community.

The Harambee Nursing Center aims to improve residents’ health and well-being through affordable, trusted, wellness education, prevention, and primary care health care given by nurses and other health providers who are actively engaged and committed to residents, where they live.

Program Description

The Harambee Nursing Center is a nurse-led, non-profit organization located in the Smoketown area of Louisville, KY. Because of recent challenges to the financial sustainability, the National Nursing Center Consortium (NNCC) serves as the fiduciary agent. The Presbyterian Community Center, University of Louisville Hospital, and Louisville Metro Housing Authority are strong partners. Four Schools of Nursing place students for community health experiences. Nurses staff a weekly health clinic where residents can walk-in for health care for acute and chronic health problems, wellness education, weight management and/or assistance in obtaining access to needed healthcare. Current health promotion initiatives include health literacy education; teaching the community how to prevent injuries, give First Aid and perform timely CPR; education about breast cancer detection and treatment to the Somali Bantu residents; sports physicals, flu vaccine and health lifestyle behaviors.

Evidence of Success

• Strong support by community residents and partners led to rebuilding Harambee, after the primary care clinic closed in June 2010.
• Health care access provided to 62 residents in a weekly clinic (528 contact hours and 186 unduplicated visits). 90%were uninsured.
• Funding secured from the Good Samaritan Foundation, a founding donor.
• Flu vaccine was given to 50 residents, onsite mammogram to 30, sports • exam to 35 youth
• 443 educational encounters related to healthy behavior provided to community residents
• 26 community service providers certified in CPR; 16 received non-certified CPR
• 125 community residents targeted to be trained in CPR Family and Friend or CPR
• 52 nursing students from 4 school of nursing, received clinical supervision by Harambee
• Unnecessary use of emergency services prevented on at least 62 residents.
• Cost of primary care is reduced by half or more on each client.

Background and Goal

Pediatric palliative care is an under-funded and often overlooked element of theU.S. health care system. (Palliative care reduces or relieves pain from serious illness regardless of the diagnosis or prognosis. Although it can be part of hospice care, it also can be provided to those with non terminal conditions – and includes physical, mental, emotional, and spiritual support for the patient and their family. It is provided by an inter-professional team that includes nurses, doctors, social workers, child life specialists, chaplains and other related specialists who collaborate across settings from hospital to home.)

The Harriet Lane Compassionate Care Program mission is to improve the care and comfort for children of all ages with life threatening and life limiting conditions by advancing the art and science of pediatric palliative care. Our vision is comforting children every day.

Program Description

The Harriet Lane Compassionate Care Program (HLCC) is a nurse-directed holistic approach to interdisciplinary, pediatric palliative care at the Johns Hopkins Children’s Center in Baltimore. It provides education, support and renewal with a unique focus on building confidence and competence in interdisciplinary health care professionals. A full spectrum palliative care clinical program, including palliative care consultation, pain and symptom control, psychosocial and spiritual support, advance care planning and bereavement counseling has been developed. The program coordinators develop innovative, experiential education and support systems, including regular debriefings with professionals after patient deaths. The program also includes a 50 member interdisciplinary network and an interdisciplinary leadershipCommittee.

Evidence of Success

• One of the first pediatric palliative care programs in the country and uniquely co-led by a doctorally-prepared nurse.
• The team leads weekly inter-professional care planning rounds that include interdisciplinary representatives from inpatient units, Pediatrics at Home and local hospices to discuss challenging cases. Other changes from conventional care include weekly goals of care.
• Conferences in pediatric and neonatal intensive care, a peri-natal consultation pilot program.
• Our pilot palliative care consultation program serves 40-50 patients per year whose care exceeds the capacities of their primary clinical team.
  
• We developed a comprehensive bereavement program for families while providing support to the inter-professional clinical teams.
• Staff debriefings are offered after each patient death; formal debriefing sessions are provided 2-3 times a month.
• The bereavement program serves more than 250 families each year. Examples of the services provided include: support groups for siblings as well as parents and grandparents, annual retreats for families, referrals and resource provision, including funeral assistance, and follow-up for families for two years after a child dies.
• Annual tribute and memorial services for families and health care team members honor patients who have died.
• HLCC leaders have developed and disseminated national and international clinical quality standards and inter-professional, patient and family centered curricula in pediatric palliative care.
• System-wide palliative care education is integrated into clinician orientation, continuing education and annual inter-professional 1-day conference.
• HLCC has provided leadership in state-wide policy initiatives to address gaps in pediatric palliative care services
  

Background and Goal

In 2014, the University of Hawaii at Manoa Nursing (UHM) and the Hawaii StateDepartment of Education (HIDOE) partnered to create the Hawaii Keiki: Healthy and Ready to Learn program (Hawaii Keiki) to address the impact of health on student attendance and learning especially focused on the needs of Title 1schools.

The Hawaii Keiki program was developed to provide access to no-cost school nursing services in Hawaii public schools. The program is enhancing and building school-based health services that screen for treatable health conditions; provide referral to primary health care and patient-centered medical home services; prevent and control communicable disease; and provide emergency care for illness or injury. Students succeed academically when they come to school healthy and ready to learn.

Program Description

The program’s five core goals are: (1) reduce preventable, health-related, chronic absenteeism while minimizing interruption to instructional time; (2) enhance wellness in the school environment and community; (3) promote optimal student health through preventive screening and effective services forchronic health conditions; (4) collaborate with community partners and organizations to provide coordinated school health programs, services, and resources; and (5) promote the nursing profession.

The program was designed to be flexible and agile to respond to emerging and ongoing student, school and community needs as well as funding availability.The Hawaii Keiki RNs and APRNs are a resource to the entire school community and lead the coordination of school health services as well as assistance in school wellness promotion and health career readiness. They collaborate with and make referrals to health systems and individual care providers. Students can walk into the Hawaii Keiki school clinic or be referred by a teacher/parent and have services provided regardless of insurance status. By utilizing technology such as telehealth, the program has expanded equitable care by using RNs to connect students to the Hawaii Keiki APRN for both physical and mental health needs. With the presence of dedicated nurses in school, it allows principals and teachers to focus on education rather than students' health care.

Evidence of Success

The Hawaii Keiki: Healthy and Ready to Learn model has expanded access to healthcare and reduced health disparities for children and contributed to an emerging body of evidence on school health. During the COVID-19 pandemic, the Hawaii Keiki program continued to grow in size and scope to meet the needs of the students, community, and schools. When the state’s public schools closed during the pandemic, the program launched a hotline answered byHawaii Keiki nurses to provide health advice, information on community services, as well as to conduct telehealth visits upon request.

School Nursing Services (in operation since 2014) 

• Expanded from 59 schools served in 2014, to all 258 public schools across the state in 2023.
• 75% of students in 2022-2023 returned to class instead of being sent home after a visit to a Hawaii Keiki clinic.
• Grown from 4 nurses to approximately 160 registered nurses, advanced practice registered nurses, dental hygienists, dentists and health technicians in 2023.
• The program now offers: school nursing, telehealth, mental health services, dental services, health hotline, Vaccines for Children and recently expanded services to Hawaii Charter Schools.
• 82% of Hawaii public schools participated in the Hawaii Keiki Narcan/CPR training initiative to reduce potential opioid overdose on school campuses.

Dental Services (in operation since 2020)

• Provides no-cost dental screening focused on high-need schools and has received on-going grant funding from Hawaii
• Expanded services from 6 schools on one island in 2020, to 68 schools on three islands in 2023.
• 61% of students in 2022-2023 who received dental assessments received dental sealants.

Promotion of Health Professions

• Provides training and education for School Health Assistants (HIDOE employees) to increase their lifesaving and first-aid skills.
• Provides clinical experiences for University of Hawaii students from nursing, dental hygiene, pharmacy, sociology and psychology departments.
• Actively supports the HIDOE Career Pathways by engaging with high school student health academies and career fairs.

Background and Goals

Non-ventilator associated hospital acquired pneumonia (NV-HAP) is one of the most common and deadly hospital-acquired infections in the United States, leading to an estimated 6.3 million deaths and over $3 billion in annual costs. Despite the widespread risk, NV-HAP is not predictable at admission, and all patients are at risk. Research has shown a strong link between poor oral hygiene and development of pneumonia, with 70% of hospitalized patients in the U.S. not receiving adequate oral care assistance during their hospital stay, significantly increasing their risk. Missed oral care can lead to severe consequences, including NV-HAP, sepsis, longer hospital stays, higher costs, and reduced quality of life. Moreover, the absence of mandatory tracking has left many U.S. hospitals unaware of the problem and potential harm to patients. 

The Hospital Acquired Pneumonia Prevention by Engaging Nurses (HAPPEN) model addresses this critical patient safety issue by promoting consistent oral care – at least twice daily – as a simple, yet effective intervention to reduce the risk of NV-HAP. The goal of the model is to provide the highest quality care possible to address this critical safety issue, reducing NV-HAP and improving the health and well-being of patients within and outside the U.S. Department of Veterans Affairs (VA). 

Program Description

HAPPEN is a VA team-based model grounded by the initial work of Dr. Dian Baker and her colleagues working in civilian hospitals, with the goal of preventing NV-HAP through consistent oral care. The implementation process began with a thorough gap analysis at pilot sites, which informed the development of the model and its components. HAPPEN emphasizes participatory action research and the Influencer Model, focusing on evaluating performance gaps, ensuring the quality of implementation, and providing ongoing support and education. 

Nurse leaders and frontline staff were actively engaged in developing the implementation process through individual meetings and monthly Community of Practice calls. These platforms facilitated discussions on barriers, challenges, and facilitators of sustainment. Critical to the model’s structure is the building of cohesive interdisciplinary teams, the gathering, interpreting, and disseminating of data, and collaborating with patients to strengthen their self-management related to oral care. The team also implemented monthly tracking of NV-HAP rates using an internal dashboard, enabling the evaluation of the model’s impact at national, regional, and local levels. Through its comprehensive and collaborative approach, HAPPEN advances patient safety and sets a new standard in pneumonia prevention.

Evidence of Success

Supported by the development of nurse-sensitive quality indicators to measure the frequency of oral care, HAPPEN has demonstrated improved clinical outcomes, including: 

• NV-HAP rates decreased from 1.56 cases per 1,000 patient days in 2015 to 0.9 cases in 2021. 
• Despite a spike in NV-HAP cases among COVID-19 positive patients during the pandemic, the aggregate NV-HAP rate continued to decline over time to 0.12 cases per 1,000 bed days of care as voluntarily reported to the VA Inpatient Evaluation Center in Fiscal Year 2024. 
• The financial impact of the HAPPEN model has also been substantial, demonstrating cost savings and efficiency: 
• The prevention of NV-HAP has driven rates down to less than half in VA acute care units, with significant cost avoidance. 
• Reduced complications associated with NV-HAP, leading to lower overall health care costs. 
• Noteworthy cost-effectiveness, with an estimated oral care supply cost of $3-5 per patient, per admission. 
• Expansion to all 155 VA medical centers by July 2021, validating its cost-effective implementation. 

The HAPPEN model has had a profound impact beyond the VA health care system by offering essential education on pneumonia prevention to patients, families, and caregivers across diverse care settings. Recognized as a best practice by the Office of Nursing Services and highlighted by the Centers for Disease Control and Prevention, HAPPEN has earned notable awards, including the 2021 Veterans Health Administration’s National Dissemination Award and the 2020 Gears of Government President’s Award for Innovation. The model’s national recognition reflects its transformative effect on patient safety and its role as a leading example of nurse-led innovation.

Contact Information

Shannon Munro, PhD, APRN, BC, FNP, Nurse Researcher/ Implementation Scientist and Nurse Practitioner, Department of Veteran Affairs Medical Center, https://marketplace.va.gov/innovations/project-happen 

Additional Contributors

Dian Baker, PhD, APRN, Professor and Nurse Researcher, School of Nursing, California State University in Sacramento, dibaker@csus.edu 

Past Contributors

Blake Henderson, Director, VHA Diffusion of Excellence, VHA Innovation Ecosystem

Michelle Lucatorto, DNP, FNP-BC, Associate Director, Analytics (Retired), Veterans Health Administration, Office of Nursing Services 

Sheila Cox Sullivan, PhD, RN, EBP-C, Director, Research EBP & Analytics, Veterans Health Administration, Office of Nursing Services 

Karen K. Giuliano, PhD, RN, FAAN, MBA, Co-Director and Associate Professor, Elaine Marieb Center for Nursing and Engineering Innovation, University of Massachusetts Amherst and Elaine Marieb College of Nursing and Institute for Applied Life Sciences

Background and Goal

Presently, there are 124 nurse anesthesia programs in the United States, including Puerto Rico. The majority of these graduate programs are housed in predominantly White institutions; eight are in Hispanic-Serving Institutions (HSIs) and none are in Historically Black Colleges & Universities (HBCUs).

In 2006, there were 94 nurse anesthesia programs nationwide. In addition, there were 37,000 nurse anesthesiologists, 6% came from marginalized racial and ethnic backgrounds, and 94% were majority White. As the number of programs has grown, the number of nurse anesthesiologists has increased as a result. However, the population of nurse anesthesiologists has not kept pace with the changing demographics of America. Since that time, according to the American Association of Nurse Anesthesiology’s 2020 Profile Survey Reporting, of the 59,000 CRNAs, the majority continues to emerge as White with only a 12% aggregate number of diverse professionals. The racial and ethnic composition of Nurse Anesthesiologists comprises 88% White, 4% Hispanic, 3% African-American/Black, 4% Asian/Pacific Islander, and 0.7% AmericanIndian/Alaskan Native.

The Immersion Model of Diversifying Nurse Anesthesia Programs (Immersion Model) has worked to increase the racial and ethnic diversity of the pool of applicants seeking admission into most of the 124 nurse anesthesia programs, extend pipeline mentorship programs to nursing students of color, and increase professionals with PhD and doctorate degrees with nurse anesthesia subspecialties. Empowering diverse nurses with information and mentorship regarding becoming a certified registered nurse anesthesiologist (CRNA)directly increases the pipeline to a rich applicant pool. Despite the many factors of systemic racism that are often at play, this pipeline was designed to translate to an increase in the racial and ethnic diversity of nurse anesthesia student cohorts, nurse anesthesia faculty, and anesthesia content experts.

Program Description

The Immersion Model is built on two constructs, mentorship, and early professional socialization, and is executed through three pipeline initiatives. The overarching goals are to expand access to diversity pipeline initiatives, performa manpower analysis to support initiatives with increased funding, and build a collective of PhD researchers as well as CRNAs of color leading and practicing in anesthesia subspecialties.

The first initiative builds on the professional socialization of diverse registered nurses interested in nurse anesthesia. Early professional socialization is implemented before and during the stages of application, interviewing, and admission into a graduate nurse anesthesia program. The Diversity CRNAInformation Session & Airway Simulation Lab Workshops are held at select graduate nurse anesthesia programs across the country. Also, providing the participants with a comprehensive experience as they consider graduate nurse anesthesia programs.

During the three-day event, historically excluded marginalized diverse registered nurses are provided with a direct opportunity for engagement with diverse nurse anesthesiologists, nurse anesthesia program faculty, and currently enrolled nurse anesthesia students. Beyond the networking opportunities, the Diversity CRNA Information Session & Airway Simulation LabWorkshop is designed with intention as it provides exposure to the profession through content that is relevant to the practice of anesthesia. The Information Session & Airway Simulation workshop is a three-day event that includes presentations on the admissions process, optimizing essay construction, nurse anesthesia program curricula, clinical preparedness, balancing family and finances, ideas for doctoral program scholarly projects with an equity lens, and opportunities for participation in live mock interviews. The mock interviews are conducted with participating nurse anesthesia program faculty who are committed to providing constructive feedback to the participants. Mock interviews have served as a reliable method to boost confidence and interview preparedness through practice, critique and a facilitated group discussion.

The Airway Simulation Lab Workshop provides the attendees with hands-on exposure to simulated clinical anesthesia techniques. While working with CRNA preceptors, participants are taught, through demonstration and return demonstration, about the use of a variety of airway management devices and other anesthesia equipment. This level of engagement provides the opportunity for nurses of color to grow in their knowledge base and have tactile experiences that will support their learning and understanding of airway anatomy, airway management, and anesthesia equipment that is commonly used in practice.

The second initiative is the Diversity CRNA Historically Black Colleges &Universities and Hispanic-Serving Institutions (HBCU & HSI) Schools of NursingTour. The goal of this initiative is to inform nursing students earlier in their careers about the nurse anesthesia profession. In addition, to encourage their pursuit of higher education in doctoral nurse anesthesia programs, and to offer access to a network of diverse nurse anesthesia professionals. This program is a full-day event where diverse nurse anesthesiologists engage with nursing students about their professional career trajectories. Towards the end of this one-day program, a hands-on Airway Simulation Lab Workshop is offered as an opportunity for exposure and hands-on experience that is integral to the eventual understanding of anesthesia equipment. The simulation lab workshop supports their curiosity as that is necessary for the development of an interest in, and an appreciation for, the clinical aspects of nurse anesthesia practice.

The last initiative, the Diversity CRNA Advanced Practice Nurse DoctorateSymposium, is designed for diverse marginalized advanced practice nurses, registered nurses and nursing students interested in pursuing a doctorate degree (PhD, EdD, DNP, or DNAP). A panel consisting of doctorate-prepared and diverse Nurse Anesthesiologists, Nurse Practitioners, Family Nurse Practitioners, and Nurse Midwives share details of their journey and provide the participants with an overview on the process associated with building a body of scholarly work.

Evidence of Success

For over a decade, the Diversity in Nurse Anesthesia Mentorship Program has mentored 658 nurses of color who matriculated into and graduated from 92 graduate nurse anesthesia programs.

This mentorship has supported an increase in racial and ethnic representation in the nurse anesthesia workforce from 6% in 2006 to 12% currently.

In 2022, there are 166 nurse anesthesia students of color enrolled in nurse anesthesia programs who have participated in past Diversity CRNA events. Eight of these diverse nurse anesthesia students attended a Diversity CRNA HBCU & HSI Schools of Nursing Tour when they were senior nursing students in 2016.

The Immersion Model is innovative by design and has emerged as a reliable method to challenge bias, close demographic gaps in representation, and increase the racial and ethnic diversity of the nurse anesthesia profession. Three Diversity CRNA initiatives, by utilization of this model, have demonstrated success over time by positively impacting the growth of diversity in the nurse anesthesia profession. Today, as a result of this model, there are more racially and ethnically diverse nurse anesthesia program faculty, along with an increasing number of advanced pain management fellows, PhD researchers, and doctorate-prepared CRNAs. Presently, over half of the nurse anesthesia programs across the country are making policy changes to decrease structural barriers to admission such as those inherent within the process and evaluation of standardized testing. By adopting a holistic approach to the evaluation of academic preparedness, evaluation of admission criteria, and processes for application review, we have seen an increase in the racial and ethnic diversity of the student applicant pool and ultimately the nurse anesthesia student cohorts across the United States.

This innovative model was designed and implemented to lead and support the growth of diversity in the nurse anesthesia profession. Through strategic initiatives, valued partnerships, regular evaluation, and organizational growth, the Immersion Model, and the work of The Diversity in Nurse Anesthesia Mentorship Program has made a profound measurable impact. These initiatives will continue as an example and a force toward positive outcomes for communities of people who have been marginalized and historically underrepresented for far too long.

Background and Goal

Growth is the single most important indication of a child’s health. Benefits of growth monitoring include identification of chronic disorders and reassurance to parents that the child’s growth is within normal range. However, pediatric endocrinology nurses have determined that linear grow this often inaccurately assessed – resulting in the lack of follow up and referral of a child with growth failure, or the inappropriate referral for treatment of a normally growing child.

The goal of this training is to assure greater accuracy of linear growth measurement, so that correct decisions are made about whether a child needs further evaluation for a growth disorder

Program Description

This is a two-hour training session that includes a written pre-test of knowledge of age-appropriate growth velocity and accurate linear growth measurement, along with a PowerPoint presentation and handouts reviewing the physiology and pathophysiology of growth disorders and linear growth monitoring techniques. It also includes how to correctly plot measurements on growth charts, the use and accurate installation of measurement equipment, a demonstration/return demonstration of proper length and height measurement technique, and a written post-test assessment. The demonstration session includes practice on performing recumbent length measurements on infants (2 years of age).Accuracy of a measurer’s length and height measurements are assured through inter-observer reliability between the nurse trainer and the measurer and also the measurer’s repeated measurements on the same child. Measurements are considered acceptable if the difference between the trainer and the measurer did not exceed 0.5 cm.

Evidence of Success

• In evaluating the linear growth assessment of 878 children measured by 127 measures in 55 primary care/family practices in a randomized controlled trial in eight U.S. cities, a baseline assessment showed only 30% of the children were measured accurately.
  • At a six-month reevaluation visit, 74% of children in the intervention group and 26% of children in the control group were measured with correct technique
  • Accuracy of measurements was also greatly improved. At six months after the intervention, 70% of the children measured in the intervention group practices and 34% of the children measured in the control group practices were measured accurately.
• Accurate screening of linear growth is cost effective – The cost of measuring equipment (approximately $200) plus the small cost to train measurers is not expensive. A 2007 study in the British Medical Journal looked at 12 height screening programs. The study used economic modeling to demonstrate how accurate height screening, by facilitating a variety of actions that eliminate or mitigate long-term health problems, enhances a child’s quality of life and saves up to £30,000 ($58,500) per Quality Adjusted Life Year (QALY).
• This is the first program providing demonstration/re-demonstration component with outcome data related to the accuracy of the measurers’ measurement technique and accuracy.
• The program was adapted for a study by Roche Products Ltd, a UK company, to evaluate whether a medication to treat juvenile idiopathic arthritis improves growth velocity in their study “Evaluation of the efficacy and safety of long term use of tocilizumab in patients with active systemic juvenile idiopathic arthritis (sJIA)”.
• The program is being used internationally in 65 locations including: the United States, Canada, throughout Europe, Latin America and Australia.
• The program was utilized in the development of the Linear Growth Assessment Guideline by Jan Foote, DNP, ARNP,CPNP to be published on the website of the National Guideline Clearinghouse, an initiative of the Agency forHealthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.
• Nurses in specialty clinics at Children’s Mercy Hospital were trained in linear growth assessment using this program
• The program is being utilized to certify all registered nurses on linear growth assessment at Children’s Hospital of Philadelphia, PA.

Background and Goal

Children who are economically disadvantaged encounter multiple, interactive stressors that frequently compromise their development and well-being. A downward developmental cascade often begins when their minor behavioral problems evolve into more serious social, behavioral, and academic problems. The aim of INSIGHTS into Children’s Temperament is to enhance the development of low-income children.

Program Description

INSIGHTS is a social and emotional learning intervention with three programs: a curriculum for children in the primary grades; a parenting program; and a professional development program for elementary school educators. INSIGHTS is also available for after school programs. 

INSIGHTS provides parents, educators, school nurses and other caregivers with practical strategies tailored to children’s different personalities/temperaments. The intervention teaches children strategies for problem-solving their daily dilemmas and enhancing their self-regulation.

INSIGHTS features four temperaments: shy, social and eager to try, industrious, and high maintenance. The temperaments are portrayed in videos by puppets in the children’s program and by actors in the adult programs.

Evidence of Success

The efficacy of INSIGHTS was tested in four federally funded randomized clinical trials. The results demonstrated that INSIGHTS:

• Reduces the behavior problems of children with ADHD to normal levels without the use of medications;
• Improves the behavior of children who exhibit minor annoying behavior problems such as forgetting their homework;
• Enhances the reading and math achievement of children;
• Increases children’s engagement and attention at school;
• Enhances parenting skills; and
• Increases the emotional support of teachers for their challenging students.

INSIGHTS continues to evolve. All curriculum materials have recently been updated so that they are available remotely. INSIGHTS has been in urban and rural communities in the United States and in Jamaica and in Canada. The parenting program has been culturally adapted into Spanish. More information is available at insightsintervention.com.

Background and Goal

Individuals with serious mental illness (SMI) are at higher risk for serious conditions such as cardiovascular disease, diabetes, and obesity because they are less likely to access health care services. The lack of proper health care for this high risk population results in increased mortality rates and a life span that is 25 years less than the general public. Integrated Healthcare Center’s goal is to dramatically improve health outcomes of people with SMI by transforming fragmented physical and mental health care to an integrated evidenced-based system of care provided by Advanced Practice Registered Nurses (APRNs) in collaboration with community partners.

Program Description

Integrated Health Care (IHC) is a nurse-managed center with the University ofIllinois at Chicago (UIC) College of Nursing run by faculty APRNs which provide integrated, ongoing primary and preventive care, education, behavioral and mental health care to individuals with SMI. IHC coordinates care withThresholds’ (Chicago’s largest interdisciplinary freestanding psychiatric rehabilitation organization) case managers and psychiatrists. Services are provided in four clinics. Recognizing clinic-based services remained inaccessible for homebound Thresholds’ members, IHC received 5 year HRSA funding in 2008 and began ‘IHC Without Walls’ (WOW) for the homebound population. IHC also received one of ten Affordable Care Act awards to nurse managed centers to expand services to underserved populations and increase capacity for NursePractitioner education.

Evidence of Success

IHC Clinic-based clients:

• Lower blood pressure: 67.2% of members with hypertension had blood pressures less than 140/90. Of those with elevated blood pressures in 2011, 83% had normal blood pressures on their most recent visit.
• Lower cholesterol: 11.6% decline in total cholesterol and a 13% decrease in low density lipoprotein (LDL) cholesterol. Of the patients with one or more reading over 100, 73% demonstrated a 5 point drop in LDL in 2011, with a number of dramatic drops such as a decrease of 96 points from LDL 161 to LDL 65 and a decrease of 83
  points from a LDL 153 to LDL 70.
• Lower blood sugar: 22.9% decline in hemoglobin A1c or blood glucose levels; 88% of A1c tests performed on the entire at-risk for diabetes population were below 7; 75% of those with diabetes were below 7.
• Weight loss: 73% of clients had a 3% or greater loss in body weight or remained stable.

IHC WOW clients:

• Lower blood sugar: 86% of diabetic members had blood sugars with normal range of A1c blood results which meet American Diabetes association standard, and exceeds our target of 75%.
• Blood pressure: percentage of patients in Group Homes exceeding our blood pressure target of 140/90: Group Home 1=77%; Group Home 2=83%; Group Home 3=86%; Group Home 4=69%.
• Weight loss: 60% of obese members lost weight and 24% stabilized their weight.
• Mental health status: 47% of WOW clients had an increase in mental health status scores, and 21% stabilized.
• Qualitative results: Telemonitoring showed promising results, with two members’ improvement leading to independent living, and another member attributing telemonitoring to his success in smoking cessation

Background and Goals

Health care delivery systems strive to create accessible, equitable, and culturally fluent care that provides value-based care to diverse populations. Many communities, including those in rural areas, previously incarcerated individuals, refugees, and underserved populations, often face significant barriers to receiving comprehensive, coordinated care. The INSMI (Integrated Nurse-led Model of Sustainability and Innovation)/ NP-CSI (Nurse Practitioner-Clinic Sustainability & Innovation) model aims to bridge those health care gaps. 

The INMSI/NP-CSI was developed between 1994-2024, with its earliest focus on primary care workforce development in rural Virginia. Over time, the model has expanded across rural and urban regions in Indiana, Texas, and California, evolving into a network of 14 nurse practitioner-led clinics, including a Neonatal Intensive Care Unit Follow-up clinic. The model aims to promote health equity and social justice by developing culturally proficient clinical teams and fostering community partnerships through trust-building and empathic communication. Another key goal is to create sustainable healthcare delivery systems through strategic business planning, evidence-based practices, and securing diverse funding sources, including grants and philanthropic contributions. 

Program Description

The INSMI/NP-CSI is structured around 12 key principles that prioritize relationship-based communication, cultural proficiency, and value-based healthcare delivery. Strong community partnerships and the use of advanced technology, including customized health records, are essential components of the model. These tools ensure care accessibility continuity, and efficiency while promoting patient safety and quality outcomes. The model also emphasized interprofessional collaboration, integrating learning, research, and practice across diverse health care disciplines. 

Building on best practices and evidence-based education, INMSI/NP-CSI incorporates engineering principles and the LEAN Six Sigma methodologies to streamline operations, reduce waste, and optimize resources. Rooted in the Institute for Healthcare Improvement’s Quadruple Aim, the model seeks to deliver better care, improve population health, lower costs, and enhance work satisfaction for health care providers. This innovative, high-quality, and cost-effective framework is designed to address complex healthcare challenges and promote long-term sustainability and health equity.

Evidence of Success

The INMSI/NP-CSI nurse-led model has been associated with impressive clinical outcomes: 

• In a 10-week health promotion study at the University of Texas, 90% of participants showed improved physiological measures, including lower blood pressure, cholesterol, and weight, with 80% program completion.
• Head Start clinics in San Antonio, TX and San Diego, CA achieved 98% immunization rates, reduced injury and absenteeism, and 100% completion of required health screenings through NP-led on-site clinics and mobile services.
• Patient satisfaction across all clinics is consistently high, with surveys revealing themes of respect, attentive care, and positive provider-patient relationships, with ratings ranging from 3.8 to 5.0.

The INSMI/NP-CSI model emphasizes health promotion, disease prevention, and patient-provider partnerships, creating significant cost savings and value, including:

• The INSMI/NP-CSI nurse-managed clinic model achieved better health outcomes and chronic disease management at 30%-50% of the cost compared to physician practices, as assessed by the Indiana Rural Health Association.
• Clinical enterprises and faculty practices based on the INMSI/NP-CSI model operate at 40%-50% of the cost of traditional, local, state, and regional medical models.
• Sustainable budgets were developed for each clinic, ensuring all costs are covered with a 10-20% margin for future growth.

The INMSI/NP-CSI model has achieved significant accolades and achievements over its 30-year evolution. The model has been featured in 70 publications, not including interviews, training modules, and conference presentations. A major highlight includes securing a large grant from the Health Resources and Services Administration in 1996, leading to the training of over 300 Family Nurse Practitioners, with 59% of graduates remaining in rural Virginia to fill critical gaps in primary care. During the model’s expansion to Indiana, five nurse-led clinics were established, serving farm families, the lower socio-economic underserved, and immigrant communities. At UT Health San Antonio, the model facilitated the development of seven clinics, including a Refugee Health Clinic and Head Start sites. The model’s global reach extended to Mexico and South Africa, supporting rural health initiatives. The model’s achievements establish it as an innovative nurse-led approach, recognized for influencing national policy and empowering nurses to advance equitable health care for underserved populations. 

Contact Information

Julie Cowan Novak, DNSc, RN, MA, CPNP, FAANP, FAAN, University of San Diego Hahn School of Nursing & Health Sciences Adjunct Professor and Director NHA Head Start Health and Wellness Van Project, University of San Diego & NHA Head Start, juliacowannovak@gmail.com 

Many school-age children lack access to quality health care and other essential services to meet their needs and support their physical, mental, and behavioral health. Dr. Nan Gaylord, PhD, RN, CPNP-PC, PMHS, FAANP, FAAN, has been providing comprehensive care to the children of Knox County, TN since 1995 through her innovative model, Interprofessional Practice at the Vine School Health Center: A School-Based Nurse-Managed Clinic. The Vine School is the physical site of the Vine School Health Center (VSHC), a Title 1 school where 100% of the students qualify for free lunch and, according to the 2010 census, the median household income for the zip code is $9,721. Locating the health center within the school ensures this vulnerable population is provided convenient access to quality care and follow-up visits. In addition to providing care for the students attending the Vine School, VSHC also provides care to anyone from 0 to 21 years of age who will be, or is, a student in the county. There are ten additional schools served by the Vine School Health Center, through either direct health care or telehealth services, and all of these schools are Title 1 schools with at least75% of the students qualifying for free lunch.

Program Description

When the VSHC opened in 1995, its primary focus was providing quality primary physical healthcare by APRNs, nurses, and student nurses within the school facility. In 2011, recognizing that many of its students had unmet social, academic, and mental health care needs, the VSHC expanded to an interprofessional practice to meet these needs through a three-year Nurse Education, Practice, Quality and Retention (NEPQR) Program grant. The expansion of services also enabled the center to assist families with issues including food resources, housing, clothing, insurance, financial support for rent and utilities, as well as individual and family therapy. The VSHC also expanded its delivery method to include telehealth services to ten additional schools in Knox County with a HRSA School-Based Health Center Capital Program. With only 7%of the 2315 school-based health centers in the country utilizing telehealth, the VSHC became a model of innovation for healthcare solutions through nurse-designed and nurse-managed care. In addition to the availability of telehealth services on weekdays between 8:00 a.m. and 4:30 p.m., a nurse practitioner is on site at each of the schools at least ½day/week to provide Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) exams and follow-up on telehealth visits.

Evidence of Success

During a three month period in the 2016-2017 academic year, a total of 130 patient satisfaction surveys on the VSHC services were collected with an overall care rating score of 4.67 out of 5. In these surveys, 77% of the patients reported that VSHC was their primary care provider. Of the 33 parents utilizing VSHC’s telehealthcare services in April of 2016, 100% reported being satisfied with the care received. Similarly, the 75 patients in ongoing mental health therapy in 2016/2017 reported a patient satisfaction rating of 4.9 out of 5. In addition to the quality of care provided by VSHC, the increased access to care is evidenced by the 1110 Early and Periodic Screening, Diagnostic and Treatment (EPSDT) exams, 1896 immunizations, 4455 physical health visits, and 1796 mental health clinic visits within the 2016/2017 academic year. With acute care concerns (typically 2500 plus an academic year) frequently addressed with a visit to the emergency room for $300 more than the standard cost of care at VSHC for the same diagnosis, the health care system realizes a cost savings of $375,000 if even half of these 2500 patients receive care at VSHC instead of the emergency room. In the April 2016 survey completed by the 33 VSHC telehealth patients, 28.5 percent of the parents reported they would have taken their child to the emergency room for care had the VSHC telehealth service not been available – equating to a savings of $1800 for just that one month in April.

Background and Goals

The opioid crisis disproportionately impacts pregnant and parenting women and people (PPWP), as incidence of opioid-related diagnoses during pregnancy more than doubled from 2010-2017. In Pennsylvania, nearly 16 of every 1,000 births were affected by maternal opioid use in 2017.  Additionally, overdose is now the leading cause of maternal mortality in Philadelphia, PA and many other parts of the country.  The health care challenges faced by PPWP with opioid use disorder (OUD) and other substance use disorders are a myriad. These include limited access to health care, barriers that prevent health care utilization, stigma and discrimination from health care and broader systems, childcare needs, inadequate social support, food insecurity, and housing insecurity just to name a few. 

The Jefferson Center for Maternal Addiction Treatment, Education, & Research (MATER) is a transdisciplinary clinical, academic, and research unit currently housed within the Jefferson College of Nursing at Thomas Jefferson University in Philadelphia, PA. MATER seeks to address the complex challenges faced by PPWP with OUD by providing comprehensive treatment: inclusive of medications for OUD; prenatal/postpartum health care; psychiatric care; individual, group, and family therapy; peer support; and other wraparound services that are highly effective at improving maternal and neonatal outcomes. MATER aims to address the medical, psychiatric, and behavioral conditions of OUD and other substance use disorders among PPWP and families, along with the social and environmental factors that contribute to family health. MATER's end goal is to help families thrive and prevent the intergenerational transmission of addictions. 

Program Description

MATER operates in a democratic structure grounded in collaboration, mutual accountability, trust, and inclusion, providing care through a transdisciplinary model. This approach is reflected at all levels, from direct patient care to program leadership, ensuring cohesive and patient-centered care.  

At the patient-care level, each PPWP and their family received personalized care from a team tailored to their needs. The team typically includes a nurse practitioner, a registered nurse, master’s level therapist(s), certified recovery specialist, care coordinator, and child development specialist. Together, they collaborate on evaluation, treatment planning, and care provision. Weekly team meetings allow for ongoing adaptation of care to the evolving needs of each PPWP and their family. MATER’s offerings also evolve with the needs of the community, guided by a Community Advisory Board and active research team. 

Two key elements in MATER’s care are the work to address parenting skills and stress, and developing self-empowerment, education, and guidance regarding employment opportunities. MATER offers Mindfulness-Based Parenting (MBP), a 13-week group intervention that enhances parenting behavior and reduces stress. The team has also developed MATER Academy, a peer-led group comprised of Certified Recovery Specialists which support self-empowerment, education, and career development for women in the program, creating community and fostering long-term success. MATER’s innovative and community-centered model not only addresses the immediate medical, psychological, and social needs of PPWP’s and their families but also empowers them with the tools and support necessary for long-term success. 

Evidence of Success

MATER has demonstrated significant clinical and financial outcome improvements through its innovative interventions: 

• MATER's trauma-responsive Mindfulness-Based Parenting (MBP) Intervention has led to notable reductions in stress, improved parenting, and increased mindfulness. Participants who completed MBP demonstrated statistically significant decreases in general stress, especially among those who reported high levels of general stress at baseline (before MBP).
  
• Parenting outcomes improved across key domains, including supporting confidence, promoting learning, and building relationships.
• Following the success of MATER Academy, Community Behavioral Health collaborated with MATER in 2023 to secure a dedicated billing code and reimbursement rate for the Academy’s services. 

Additionally, the MATER model has made significant community and policy impacts on the local and national stage: 

• Engaging Mater Academy graduates and members at varying stages of recovery, the Community Advisory Board meets monthly to engage with and consult on MATER’s research studies, guide conference and event presentations, and provide input on community services. 
  
• MATER faculty and staff have worked with hospital systems across Philadelphia to implement universal screening for substance use disorders during care for pregnant women and people. 
• MATER’s faculty, staff, and patients with lived experience contributed to defining the term "substance-exposed infant" and guided policy updates on interpreting maternal and infant toxicology testing in the context of pregnancy and substance use care.

The MATER model has received many accolades for its work. In 2024, MATER hosted its first annual conference, “Community Roots of Recovery,” drawing approximately 130 attendees from over 20 organizations across Philadelphia. MATER faculty have made over 40 conference presentations and 30 peer-reviewed publications in the past five years. MATER’s impact was recognized nationally when they were invited to host a White House summit on neonatal abstinence syndrome in 2018, attended by experts, the United States Assistant Secretary for Health, and the First Lady. MATER’s achievements highlight the broad and important influence of the model’s community and patient-centered care for PPWP. 

Contact Information

Marie Ann Marino, EdD, RN, FAAN, Dean and Professor, Thomas Jefferson University, College of Nursing, MarieAnn.Marino@jefferson.edu 

Additional Contributors

Susan Aldridge, PhD, President, Thomas Jefferson University

Dennis J. Hand, PhD, Associate Professor, Thomas Jefferson University, College of Nursing, and Executive Director, Jefferson Center for MATER

Kimberly McLaughlin, PhD, LPC, Assistant Professor, Thomas Jefferson University, College of Nursing, and Executive Director, MATER

Past Contributors

Diane Abatemarco, PhD, MSW, founding Executive Director of the Jefferson Center for MATER

Karol Kaltenbach, PhD, Director of MATER

Loretta Finnegan, MD, Founder and Director of MATER

Low wage and demanding independent contractor jobs such as assistant trainers, grooms, hot walkers and stable workers are essential to Kentucky’s thoroughbred horse racing industry. These migrant jobs which require workers to follow the horse racing circuit, spending the majority of the year in Kentucky, and then traveling to other states in the winter and summer months. As independent contractors earning on average $15,000 a year, health insurance is neither provided nor affordable. For those on work visas, government health assistance is not an option, leaving the emergency room as their only source for primary care. A significant percentage of this population is Hispanic and Spanish speaking, unfamiliar with the language and surrounding culture. The demands of the job, often beginning at 4:00 a.m. seven days a week, coupled with isolation from loved ones, takes a toll on the physical and mental health of the migrant racetrack worker. Beginning in 2005, Dr. Whitney Nash, PhD, APRN and the Kentucky Racing Health Services Center began to address the multiple barriers to care confronting this vulnerable population. Founding Director Nash, joined by KRHSC’s current Director, Sara Robertson, DNP, APRN have made it KRHSC’s mission to provide the full spectrum of primary care to these workers and their families, including primary and secondary prevention of chronic diseases such as diabetes, hypertension, hyperlipidemia and asthma.

Program Description

Drs. Nash and Robertson’s KRHSC is a not for profit nurse-designed and nurse-staffed clinic. Four primary care nurse practitioners work on a rotating basis, with one nurse practitioner consistently at the clinic during operating hours. In addition, KRHSC employs a women’s health nurse practitioner and a psychiatric nurse practitioner to enable comprehensive care at one location. Since physical and financial accessibility is essential for these patients, the clinic is located one block from Churchill Downs and visits are a flat rate fee of $5.00, which includes lab work. KRHSC’s care model embraces holistic, patient-centered care which includes health education and prevention, as well as health screenings and disease management. To achieve its mission, KRHSC fostered two critical affiliations – one with the Kentucky RacingHealth and Welfare Fund and the other with the University of Louisville. The Kentucky Racing Health and Welfare Fund, a not for profit entity dedicated to providing medical, dental care and retirement benefits for workers in the thoroughbred industry, provides funding to KHRSC derived from uncashed pari-mutual tickets at horse racing tracks throughout Kentucky. KRHSC’s second affiliate, the University of Louisville, coordinates with KRHSC to give students, including community nursing, nurse practitioner, Spanish language, pre-nursing, pre-medicine and medical students, as well as dental residents, the opportunity to improve patient care while advancing their skills.

Evidence of Success

KRHSC has improved access to quality care by serving 1500-1800 patients a year who, without the clinic, would either turn to the emergency room for intermittent care or forgo care altogether. To identify and treat their patients’ needs, KRHSC’s nurse practitioners order approximately 2400 laboratory tests annually, free of charge with the $5.00 flat fee, and write approximately 2700 prescriptions. KRHSC manages 30 to 35 diabetic patients at any one time, all having received anHbA1C test within the year they present to the clinic. Of these patients, 94% are prescribed metformin (or have a documented contraindication), 91% are given a referral for a diabetic eye exam, and 84% have a documented foot exam.In addition, 86% of pre-diabetic patients with an HbA1C of 6 or higher take metformin as compared to the industry average of 24%. The women’s health nurse practitioner sees approximately 240 patients a year, with 37% of these patients receiving a pap smear, and the psychiatric nurse practitioner sees about 125 patient visits a year. Notably, this increased access of care is achieved with cost savings. During the five year period prior to the opening of KRHSC, the Kentucky Racing Health and Welfare Fund expended an annual average of $629,000 to outside, independent medical providers and labs to care for workers within the horse racing industry. Since KRHSC’s opening in 2005, the Kentucky Racing Health and Welfare Fund has experienced an increase in cost savings which follows the shift of these patients away from outside, independent providers and labs to the KRHSC clinic. During the first 5 year period following the opening of the clinic,Kentucky Racing Health and Welfare Fund expensed an annual average of $567,000 for medical providers and lab expenses, equating to a 10 percent reduction in cost. During the second 5 year period since KRHSC’s opening, provider and lab costs dropped to $433,000, representing a 24% decrease from the first 5 year period.

Background and Goals

Significant barriers hinder nurses’ engagement in evidence-based practice (EBP) and research, including limited time due to heavy workloads, lack of access to educational resources and scholarly articles, unfamiliarity with the complexities of research, and a lack of organizational support for nursing research initiatives. Such challenges restrict nurses' ability to advance their research skills and knowledge, which is crucial for improving patient care, workforce, and system outcomes.

The Linking to Improve Nursing Care and Knowledge (LINK) model addresses the significant barriers that hinder nurses’ engagement in EBP and research to optimize practice and policy and advance nursing knowledge. Established in 2014, LINK seeks to foster a strong culture of inquiry and nursing scholarship by developing purposeful infrastructure through initiatives like the Office of Nursing Research and Innovation and academic partnerships with Columbia University School of Nursing and New York-Presbyterian. The model’s goals are to develop supportive infrastructure for research and scholarship, boost nurse engagement in research and EBP, and ensure nurse leaders continuously improve and invest in these areas for better outcomes.

Program Description

The LINK model is a comprehensive framework designed to overcome the barriers clinical nurses face in engaging with research and EBP. Key components of the model include integrating advanced technology, fostering academic-practice partnerships, and employing the PEACE model for EBP. The LINK program engages the Office of Nursing Research and Innovation to provide strategic direction, resources and support for translational research to enhance patient care. Academic partnerships with prestigious nursing schools further enrich the program, offering nurses access to advanced education and expert guidance. The Academic-Practice Research Fellowship Program also complements these efforts by providing a structured two-year fellowship, equipping nurses with essential research skills through mentorship, didactic training, and hands-on experience. 

The LINK model guides nurses through a systematic approach to problem identification, evidence review, appraisal, practice change, and dissemination of findings. Additionally, nursing research and EBP are integrated into professional governance structures to ensure that evidence-based decision-making informs nursing practice. The model offers comprehensive education programs such as the PEACE (Problem Identification, Evidence Review, Appraise the Evidence, Change Practice or Conduct Research, and Evaluate and Disseminate Findings) Model Deep Dive, research workshops, and an annual symposium, empowering nurses to actively engage in research, enhance their practice, and contribute to the broader healthcare community. The model not only improves the quality of care but also contributes to the professional development and satisfaction of clinical nurses. 

Evidence of Success

Since its establishment, the LINK model has driven system-wide changes and innovative care approaches, resulting in significant clinical outcomes. Examples from the Academic-Practice Research Fellowships publications highlight these impacts:

• Emergency Department Utilization: Celona, Jackman, and Smaldone (2023) analyzed emergency department use among young adults with chronic illnesses before and during the COVID-19 pandemic, informing strategies to reduce non-essential visits and manage chronic conditions effectively. 
• ICU Delirium Management: DeForge et al. (2020) evaluated an educational intervention using nurse champions to improve ICU delirium documentation, enhancing early detection and management. 
• Pediatric Mental Health: Hellerova et al. (2022) explored caregiver perceptions of mental health and barriers to their child's treatment, informing interventions to improve access and adherence to pediatric mental health care.  

The LINK model has also achieved notable financial outcomes and has made a substantial impact on community health and safety:  

• Lower educational costs through Columbia Nursing’s part-time PhD program, enhancing nursing staff qualifications. 
• LINK has enhanced care quality and outcomes across the New York Tri-State area, serving over 260,000 patients annually. 
• Played a pivotal role in the COVID-19 response, including forming a military partnership to create a public field hospital, with LINK faculty leading critical research. 

The LINK program has garnered significant recognition for its contributions to nursing practice and policy. At the state level, LINK faculty have championed expanded scope of practice legislation for nurse practitioners through New York State. Internationally, the LINK model has been adopted in several countries, showcasing its effectiveness in enhancing nursing research infrastructure and reducing the gap between evidence generation and practice implementation. The program’s robust feedback loop supports timely evidence-based practice and policy changes, maintaining top hospital rankings by U.S. News & World Report. The LINK model’s achievements demonstrate its transformative impact on nursing practice, policy, and global healthcare systems.  

Contact Information

Allison A. Norful, PhD, RN, ANP-BC, FAAN, Assistant Professor, Columbia University School of Nursing; Nurse Scientist, New York-Presbyterian Hospital, aan2139@cumc.columbia.edu 

Additional Contributors 

Reynaldo Rivera, DNP, RN, NEA-BC, FAAN, FAONL, Director of Nursing Research and Innovation, NewYork-Presbyterian Hospital; Assistant Professor of Clinical Nursing, Columbia University School of Nursing, rrr9001@nyp.org

Kasey Jackman, PhD, RN, PMHNP-BC, FAAN, Assistant Professor and Director of Academic-Practice Partnerships, Columbia University School of Nursing; Nurse Scientist, New York-Presbyterian Hospital, kej2105@cumc.columbia.edu 

Past Contributors

Elaine Larson, PhD, RN, FAAN, CIC; Anna C. Maxwell Professor Emerita and Special Lecturer, Columbia University School of Nursing and former Professor of Epidemiology, Columbia University Mailman School of Public Health

Background and Goal

Frail, inner-city seniors facing complex medical, functional and psycho-social problems who are nursing home-eligible but want to remain in the familiar surroundings of their own homes and communities. Living Independently for Elders Center strives to provide integrated nurse led comprehensive mental and physical health care and social service program through a coordinated integrated health plan.

Program Description

The Living Independently for Elders (LIFE) Center is a nurse led academic Program of All-Inclusive Care for the Elderly (PACE) program, owned and operated by the University of Pennsylvania’s School of Nursing, which provides alternatives to nursing home admissions for West Philadelphia residents. Teams of health care providers manage the complex medical, functional and psycho-social problems faced by elderly clients.

• Delivers comprehensive care 24 hour/7 day per week services through a team of primary care nurse practitioners and physicians who have privileges at the University of Pennsylvania Health System (UPHS).
• Currently provides meals, recreational activities, nursing and health care, medications, treatment, physical therapy, art and music therapy, and personal care services like laundry, showers, and hair care to more than 430clients daily. The program grows on average by 2 members per month.
• Provides round-the-clock services to poor urban residents who would otherwise need nursing home care. Clients are transported from home by LIFE vans to the LIFE Center and health appointments. At the LIFE Center, they engage in recreational activities and receive care and meals. Care is provided at home on an as needed basis on a plan of care that includes the family and older adult. The LIFE Center is responsible for care 24/7.
• Promotes independence and the highest levels of functioning while allowing choice and dignity for the members and their families.
• Serves as a model for integration of practice, education, and research, not only in nursing, but in health care.
• Serves as a model of integrating fiscal responsibility, access to service, and quality of care using aMedicare/Medicaid capitated per member per month rate.

Evidence of Success

• Acute care hospital admission for LIFE members are only 7.5 (1.7%) per 430 members – only about 2/3 the rate of those in Pennsylvania nursing home facilities.
• Emergency department visits occur at a very low rate of 2.6 (0.6%) per 435.
• High member and family satisfaction rates, preserves community neighborhoods.
• Saves the Pennsylvania Department of Public Welfare 20 percent annually in Medicaid reimbursement costs.
• Saves Medicare for cost of hospitalizations and emergency department visits.
• Is completely self-supporting and fiscally sound; earns reinvestment funds for the Penn School of Nursing.
• Nursing home services are reduced by number of admissions and length of stay.
• Care in hospital is provided by or coordinated by the LIFE nurses, social workers and physicians ensuring continuity of care delivered by a team familiar to the member and their family.
• Serves as an educational facility for interprofessional learning among nursing, social worker, medicine, dental, and rehabilitation services.
  
• Serves as an innovation learning laboratory for faculty and students in health care business and health services outcomes research that is patient-centered.
  

Poor sleep is a lifestyle factor that plays a significant role in the development of chronic disease, including type 2 diabetes, cardiovascular disease, increased rates of obesity, poorer mental health and reduced quality of life. Unfortunately, nurses, physicians and other health providers receive little to no training in sleep disorders or sleep health promotion. The negative health consequences of poor sleep exacerbate existing health inequalities experienced by Spanish-only speaking individuals residing along the United States-Mexico border. Carol Baldwin, PhD, RN, AHN-BC, FAAN, Cipriana CaudilloCisneros, MSN, RN, Luxana Reynaga Ornelas, PhD, RN and their bi-national inter-professional team, Lorely AmbrizIrigoyen, MSIS, Maria Teresa Cerqueira, PhD, Sergio Marquez Gamiño, MD, PhD and Stuart F. Quan, MD, FAASM developed and implemented Los trastornos del sueño y la promoción del sueño saludable (Spanish-language sleep program), the first ever sleep health program to support community-based health promotion in urban and rural areas on both sides of the United States-Mexico border.

Program Description

The Spanish-language sleep program incorporates various learning tools to teach community health workers, known as promotores, culturally relevant health education and promotion methods to improve sleep health. The program is incorporated into a validated lifestyles promotion manual and companion workbook (Camino a la Salud (Su Corazon/SuVida)), used to educate the promotores. Upon successfully demonstrating their knowledge and understanding of the sleep training, promotores, who work in concert with community health nurses and other community-based providers, use the training to educate individuals and families on the importance of sleep health. As respected community leaders who speak the language and understand the local culture, promotores serve as a valuable bridge between neighbors requiring health care and the nurses, physicians and other inter-professionals working to provide it.

Evidence of Success

Using 600 promotores as a representative number trained on an annual basis, 300 working within the U.S. and 300 working in Mexico, the cost savings realized by the sleep training is significant. Along the U.S. border, conservative estimates in cost savings for the care of obstructive sleep apnea (OSA), insomnia and restless legs syndrome (RLS) range from $315,000 in 2014 to $3,574,800 from 2014 through 2017. There are no extant studies of per person costs for sleep disorders in Mexico; therefore, cost savings for the sleep program along the Mexico border are extrapolated from numerous studies showing the linkage between OSA, insomnia and RLS with diabetes and hypertension, with the cost savings ranging from $145,500 to $209,700 for 2014 and $436,500 to $629,100 from 2014-2017.

Background and Goal

High rates of poor post-discharge outcomes put elderly patients back in the hospital soon after their release following treatment and up to one-third of those hospitalizations are considered preventable.

To focus on transitional care lead by master’s-prepared advanced practice nurses(APRNs) in conjunction with the patient’s entire health care team, targeting high-risk patients at risk for poor post-discharge outcomes in order to improve post-discharge outcomes. This lowers the rates of rehospitalization and thereby reducing health care costs.

Program Description

It is an evidence-based innovative model of hospital-to-home care in which APRNs work to ensure a smooth transition from hospital care to home care. The program assures that APRNs: establish a relationship with patients and their families soon after hospital admission; design the discharge plan in collaboration with the patient, the patient’s physician, other involved providers and their family caregivers; and implement the plan in the patient’s home following discharge, substituting for traditional skilled nursing follow-up. This reduces the incidence of poor communication among providers and health care agencies, inadequate patient and caregiver education and poor quality of care as well as enhances access to quality care.

Evidence of Success

• Since 1991, when compared to standard care, the TCM has demonstrated longer intervals before initial re-hospitalizations, fewer re-hospitalizations overall, shorter hospital stays and better patient satisfaction.
• A four-year trial (1997-2001) with a group of elderly patients hospitalized with heart failure, the APN Care Model cut hospitalization costs by more than $500,000, compared with a group receiving standard care – for an average savings of approximately $5,000 per Medicare patient.
• Demonstrated efficacy in translating the evidence based innovation into practice, in partnership with a major insurer (Aetna, Inc.) targeting their Medicare Advantage consumers (2005-2007). The program was offered as an ongoing benefit for their high-risk members experiencing transitions from acute care to home in a select market (2011).
• An ongoing clinical trial (2005-present) with hospitalized, cognitively impaired older adults and their family caregivers reveal similar health resource utilization outcomes as prior studies; health, quality of life and cost analyses ongoing.

Background and Goal

Veterans with PTSD, adults living with HIV/AIDS, homeless women, and professional and family caregivers are specific populations confronting significant stressors. The general population also suffers from chronic stress with information overload and interruptions caused by our technological “time-saving” devices! To address symptoms of psychological distress, Dr. Jill Bormann and colleagues led the development and research on an innovative, complementary mind-body-spiritual intervention for symptom management and well-being entitled the Mantram Repetition Program (MRP). A mantram is a self-selected word or phrase defined as sacred or having divine power, originating from ancient wisdom traditions and having a positive effect on the one who repeats it. Mantram repetition comes from the work of Sri Eknath Easwaran (1910-1999), a teacher of meditation who translated ancient wisdom into practical habits for Westerners.

Program Description

The MRP is an experiential intervention with aims of 1) choosing and using a mantram, 2) slowing down thoughts and behaviors, and 3) developing one-pointed attention for symptom and stress management. Repeating one’s self-selected mantram serves as a “pause button for the mind”—a brief respite from daily hassles shown to decrease reactivity and immediately bring the individual into the present moment for a rest. The program is hands on, portable, nonpharmacological and therapeutic. MRP can be practiced anywhere and at any time, making it both practical and sustainable. MRP also encourages the unique contributions of spiritual tools, without imposing religious dogma, to improve spiritual wellbeing, an often overlooked resource in our complex healthcare system. 

Evidence of Success

Strong quantitative and qualitative research demonstrating MRP’s effectiveness includes, but is not limited to:

• Insomnia in homeless women
• Self-efficacy in managing PTSD
• Burnout/exhaustion in healthcare workers
• Improving mindfulness in Veterans
• Decreasing fear in couples during childbirth
• Decreasing PTSD symptom severity
• Positive coping for people with HIV/AIDS
• Decreasing caregiver burden and depression in family caregivers

Cost-Effectiveness of MRP:

In a Department of Veterans Affairs-funded demonstration project comparing costs of delivering different types of meditation to Veterans with PTSD, MRP was estimated to cost $163 per person at the VA medical center in San Diego, CA and Loma Linda, CA, compared to:

• $575 estimated per person cost at the Syracuse, New York VA for Mindfulness Based Stress Reduction (MBSR), and
• $3,848 and $4,736 per person estimated cost for Transcendental Meditation (TM) at the Minneapolis VA Healthcare System, Minneapolis, MN and the Aleda E. Lutz VA Medical Center, Saginaw, MI, respectively.

Mind-body interventions, making up the core components of the MRP, have been shown to reduce emergency room (ER) visits with an estimated savings of $2,360/patient/year (Stahl, Dossett, LaJoie, Denninger, Mehta, et al., 2015).

Background and Goal

Survey studies consistently show that women prefer safe, easy to use, and effective forms of family planning. At the turn of the 21st century, women and couples who wished to use non-medical methods of family planning i.e., natural family planning (NFP), also sometimes called fertility awareness-based methods (FABM), only had the choice of natural methods that were developed 40 to 60years ago, including calendar-based (rhythm) methods and cervical mucus and basal body temperature systems to monitor fertility. These methods were often not effective in helping women avoid pregnancy, are cumbersome to use, and not easy to provide. Furthermore, they were not effective in helping women avoid pregnancy during the postpartum transition to fertility or the transition to menopause.

The challenge was to develop a system of NFP/FABM that was easy to use, easy to teach and provide, and that was effective not only among women with regular menstrual cycles but also women who were postpartum or who were approaching menopause.

The main developer of this new system, Richard J. Fehring, researched several devices that were designed to help women and couples monitor the fertile days of the women’s menstrual cycle for the purpose of achieving or avoiding pregnancy or monitoring their reproductive health. These devices included electronic thermometers, miniature microscopes to view salivary ferning patterns, and electrical resistance measures of saliva. In consultation with a reproductive endocrinologist at Loyola University, he learned about a new electric hormonal monitoring system that was developed to measure changes in estrogen and luteinizing hormone (LH) to help women to achieve pregnancy.

Fehring decided to integrate this new electric hormonal fertility monitor (EHFM) into a new NFP/FABM system to avoid or achieve pregnancy. The first system was used in conjunction with cervical mucus monitoring as a second check for estimating the fertile phase. The algorithms and protocols for the new system called the Marquette Model (MM) was launched in 1999. The MM is a modern easy to use, effective system of NFP that integrates the newest hormonal monitoring technology. In 2000, an online MM NFP teacher training program at Marquette University was developed for health professionals that included a NFP theory course and MM NFP practice course. A MM NFP medical application course was added in 2008.

Program Description

Old systems of NFP/FABM (i.e., basal body temperature and cervical mucus changes) are based upon subjective and often imprecise indictors of fertility.Subjective and imprecise indicators result in lengthened estimates of the fertile phase of the menstrual cycle and poorer efficacy. Both cervical mucus and basal body temperature changes are due to fluctuations of the reproductive hormones, estrogen, LH, and progesterone. The ability to self-measure and track out reproductive hormones is the latest advancement in menstrual cycle monitoring.

Newer hormonal monitors (e.g., MIRA, PREMOM, Oova, and Inito) provide quantitative levels of the key hormones of the menstrual cycle. These newer monitors also utilize the smart phone to measure the hormone and provide an app that graphs out the results. The newer hormonal monitoring systems also are better diagnostic tools that help in the interpretation of the women’s menstrual cycle as a vital sign for health. Women who use these monitors indicate that they provide objective indicators of fertility, are easier to use, and provide more confidence in using NFP/FABM for achieving or avoiding pregnancy. MM researchers have conducted and published several comparative and satisfaction studies to back these claims.

The MM has several cohort multisite effectiveness studies and the only randomized comparison effectiveness studies of NFP methods since the early1980s. The MM also has special evidenced-based published protocols for tracking fertility during the postpartum transition to fertility and the first six menstrual cycles postpartum. It is during the first three menstrual cycles postpartum that women/couples become pregnant not intending to. The MM involves educating women about their menstrual cycle as a vital sign for health and empowers them to use body symptoms for avoiding or achieving a pregnancy or for women’s health management. A recent (2022) study published in the Journal of Women’s Health showed no significant changes in the parameters of the menstrual cycle by users of the MM pre and post a Covid vaccine injection.

Evidence of Success

The model’s postpartum unintended pregnancy rates are based on both cycles of use and months of use – which is the latest method of calculating postpartum pregnancy rates – and our rates range from 6-8 per 100 women.(Note that the hormonal pill has a pregnancy rate around 8 per 100 women over 12 months of use.). Other major providers of NFP/FABM (e.g., the Couple-to-Couple League International) often refer their postpartum women/couples to a MM provider.
Women who are postpartum from other NFP/FABM systems often seek out MM providers. About 75% of our women/couple clients are postpartum up from around 33% in 2008. Hundreds of MM health care professionals throughout theUS, Canada, and other countries utilize these protocols. It should also be noted that our online MM teacher training program and our protocols for helping women/couples achieve pregnancy who have difficulty doing so was featured at a 2018 Office of Population Affairs Title X experts meeting in Washington, DC.

Background and Goal

Approximately 73% of patients seeking primary care have a psychological or behavioral health component connected to their chief complaint, and that percentage increases for patients with a chronic disease. When Dr. Reiss-Brennan opened her independent nursing family therapy practice in 1978, she received a regular stream of patient referrals from primary care providers uncertain of how to address their patient’s mental health needs. In 1984, to respond to this gap in care, Dr. Reiss-Brennan developed a collaborative, innovative business model to train primary care providers/clinics in mental health care and family systems concepts.

Dr. Reiss-Brennan’s innovative mental health integration care model caught the attention of Intermountain Healthcare (IH), and in 1998, Dr. Reiss-Brennan’s care model was coupled with a model on chronic medical diseases to lay the infrastructure for Mental Health Integration at Intermountain Healthcare, Utah(MHI). Through this pilot integrated care model, depression, substance abuse, anxiety and other mental health conditions were managed in IH primary care settings alongside other chronic conditions. In 2001, following the extremely positive outcomes of the pilot program, IH requested Dr. Reiss-Brennan to join their team and diffuse MHI throughout the entire delivery system.

The MHI model of care is designed to promote three essential primary care practice changes: 1) improve the detection, monitoring, stratification, and management of depression and other mental health and medical conditions; 2)reinforce ongoing relational contact with patients and their families to promote adherence and self-management; and 3) match and adjust treatment and management interventions if there is evidence of increasing complexity and/or inadequate patient response. The broad goal is to involve the patient and family in their own care and to enhance their self-management skills.

Program Description

Mental Health Integration at Intermountain Healthcare is an evidence-based, team oriented, care process that develops a family-centered care model aimed at improving mental health treatment within primary care settings. MHI re-engineers the primary care process by including peer advocates, patients, and families as integral members of the team.

MHI developed screening materials completed by each patient, as well as an interagency referral algorithm, that assures the patient is engaged at the level of care required to meet their mental and physical health needs. Team resources are allocated to meet the complexity (mild, moderate, severe) of the patient and family identified need. Team communication and coordination are further facilitated through shared electronic medical records, clinic based nursing care managers that follow patients’ progress, and patients having direct phone and email access to their physicians and team members. MHI’s team based care has been sustained throughout the life of the program and has changed the culture of mental health care delivered at Intermountain.

Evidence of Success

• Over the last 15 years MHI’s care model has been implemented in over 90 of the 160 IH clinics (including primary and specialty care clinics and community based clinics for low income families).
• MHI has also been influential in disseminating the implementation science of clinical integration in Maine,Mississippi, New Hampshire, Oregon, Arizona, Utah and overseas in France, the UK and Singapore.
• Patients with depression who are treated in MHI clinics are 54% less likely to have emergency room visits than depressed patients in non-MHI clinics.
• In 2010, patients with depression who were involved with an MHI clinic saw their health insurance claims decrease by $667 in the year following their diagnosis.
• Diabetic patients with depression gained better control of their diabetes (53.1% v. 47.5%), and 81% of patients recently surveyed said they were hopeful they could get well or stay well.

More recently, Dr. Reiss-Brennan and her research team at IH study had the opportunity to measure the longitudinal impact of routinized MHI-Team Based Care (TBC) on clinical and financial outcomes and to quantify the value of integrating mental health as an organized team process within the context of primary care medical homes. IHResearchers observed that sustained levels of routinized TBC, as opposed to traditional practice management, were associated with significant improvements in quality of care, reductions in acute care utilization and overall costs. These findings suggest that patients who have continuous, coordinated relationships within a delivery system that provides care through high performing integrated clinical teams connecting physical and mental health receive value in improved outcomes and lower costs.

The Mount Sinai Primary Care Hepatitis C Clinical and Research Program(Hepatitis C Program) was designed to address the needs of an underserved patient population with a prevalence of chronic hepatitis C infection nearly 5 times the national average. An integral component of the academic primary care practice at the Icahn School of Medicine at Mount Sinai, the Hepatitis C Program serves patients who are drawn primarily from the surrounding communities of East and Central Harlem and the South Bronx.

In addition to progression of their liver disease, the patient population most affected by hepatitis C has become increasingly chronically ill as they have aged, and requires closer and more specific follow up. Historically, social determinants of health resulted in this patient population being plagued with co-morbidities, behavioral health issues, social concerns, and substance use. These negative health factors, together with inadequate therapeutic agents, impaired the successful treatment of hepatitis C. Up to 75% of individuals with hepatitis Care unaware of their diagnosis. The goal of the Hepatitis C Program is to educate and screen at risk members of the community, link patients with chronic hepatitis C infection to care, deliver effective care and treatment through a holistic interdisciplinary practice that simultaneously addresses social determinants of health, and to transition patients to better care and improved population outcomes.

Program Description

In 2002, Dr. Gardenier designed a holistic and longitudinal program to meet the needs of patients, most of whom were ineligible for treatment by the standards of care at the time. Dr. Gardenier purposefully took a harm reduction approach, using a patient-centered, relationship-based nursing framework which engaged patients and offered assistance with any issue, either concurrently or as a lead in to treatment. The program’s outreach team targets high risk populations in the community through linkages with community-based organizations and other care providers. The team seeks to educate, screen, and then link those in need of care to appropriate resources.

Additional innovative support was provided by Dr. Weiss with his development of the Psychosocial Readiness Evaluation and Preparation for hepatitis C treatment (PREP-C; prepc.org) and HepCure (hepcure.org). PREP-C is an online structured interview tool used to assess and increase patient readiness for hepatitis C treatment. HepCure is a resource center that includes a provider dashboard, patient app, tele-education, webinar series, and patient resources. Both are available online and have the goal of expanding awareness, linkage to care, and provider capacity to treat chronic hepatitis C across clinical settings. HepCure was developed in collaboration with Dr. P. Perumalswami (Mount Sinai Division of Liver Diseases) and Dr. A. Atreja (Mount Sinai App Lab).

Evidence of Success

The number of unique patients seen in the Hepatitis C Program over the fiscal year ending in July, 2015, was 295, an increase of 80% over fiscal year ending July, 2014. The outreach and linkage to care results from the Hepatitis C Program have also shown impressive increases in recent years, a trend that is expected to continue. Of 40 patients in the program who initiated treatment during one review period, 80% had past substance use and/or mental health issues and nevertheless completed treatment at rates comparable to other populations, suggesting that comorbid patients can be managed effectively while on treatment in a primary care setting. In addition, the program demonstrated that depression did not predispose patients to treatment discontinuation. The program has served as a model duplicated throughout New York State under the grant funded initiative of the New York State Department of Health AIDS Institute to increase capacity for hepatitis C care and treatment. In addition, the program has received ongoing funding from the Robin Hood Foundation.

Background and Goal

In many of this nation’s underserved communities, the absence of clinics, pharmacies, physicians and other healthcare services directly translates to poor healthcare outcomes. For the under- and uninsured, the out-of-pocket expenditures associated with transportation to clinic locations, and co-payments for the delivery of primary care services, are cost prohibitive. It has been well documented that the best patient care outcomes of the future will directly correlate with the utilization of an interprofessional team of healthcare providers that leverage clinical, operational, and data-based solutions, to deliver the highest quality person-centered care.

The National University Nurse-Managed Clinic (NUNMC) Project sought to shift the paradigm for the provision of healthcare services by taking the interprofessional healthcare team directly to the community to deliver primary care services onsite at designated locations throughout underserved neighborhoods in south Los Angeles County, at no cost to the patients served. This novel approach is in direct contrast to the existing healthcare system, which expects patients to travel to the healthcare facility and to have the finances to pay for the services rendered. The NUNMC Project’s Interprofessional Collaborative Practice team has been providing comprehensive primary care services and monitoring trending healthcare outcomes since 2016. The NUNMC Project is the fourth in a series of multimillion dollar corporate and federally-funded nurse-led clinics designed byDr. Gloria McNeal over the course of nearly three decades. She has operationalized this model in selected underserved communities of Philadelphia County in PA, Essex County in NJ, and Los Angeles County in CA. In1994, the American Academy of Nursing initially recognized this work, naming Dr. McNeal a recipient of the coveted Media Award. In 2009, this model of care was presented in testimony before the Institute of Medicine (IOM; currently named the National Academy of Medicine), that was subsequently included in the IOM landmark publication on the Future of Nursing: Leading Change,Advancing Health, for which Dr. McNeal served as an invited co-contributor.

Program Description

The NUNMC project launched its virtual, nurse-led initiative, which augments the provision of direct care services with the utilization of telehealth care technologies, to expand the reach of the healthcare team beyond traditional clinic walls. Patients and their families are examined and treated in the familiar surroundings of their place of worship, residential drug rehab center, orSalvation Army locations. Patients are registered onsite for services within the nurse-led clinic without walls, which is embedded within a trusted community-based organization or faith-based institution. Patients are screened for third party reimbursement eligibility by a licensed clinical social worker, and evaluated for care by advanced practice nurses.

The NUNMC Project cost effectively utilizes faculty-supervised nursing and other health professions students, in collaboration with a full-time healthcare team in the provision of care. This Project uniquely created public-private partnerships, in the goal to improve access to care for at-risk populations.Working with this broad array of community-based organizations and faith-based institutions, the partnerships formed by this collaborative initiative are designed to ensure that the individual healthcare needs of the patient are met, maintaining a culturally and linguistically responsive approach to care. Further, the Project’s unique use of biometric remote monitoring systems is designed to significantly improve access to care among the residents of the targeted neighborhoods. By closely monitoring patient clinical findings on a daily basis, predictive modeling can be used to identify patient care needs. This approach to care facilitates the implementation of treatment modification early in the illness trajectory. More significantly, the use of remote monitoring applications reduces overall healthcare costs by eliminating the need for costly emergency room and urgent care visits to treat conditions.

Evidence of Success

To critically measure outcomes, the clinical team initiated a four-year longitudinal, convenience study of the Project findings. The study found that:

• Cost savings in emergency room visits were significant with an 11:1 dollar ratio yielding a savings of nearly $2 million;
• Loss to follow up was significantly reduced with a 69.9% follow up return rate at the 95% CI;
• Patient Ethnic Demographics: 49.2% were Black, 28.5% were White/Hispanic, and 4% were Asian; a small percentage of patients reported being more than one race (1.3%), and 0.2% were Pacific Islanders; and
• While a majority of the patients (58%) had Medicaid insurance, 38.6% were uninsured.

More than 46 million Americans lack health insurance coverage and are underserved by the conventional health care system.

NNCC’s and INCS’s Goal is to provide primary health care, health promotion and disease prevention services to underserved populations in urban and rural communities across the United States where there are large percentages of the underserved and uninsured. The Institute for Nursing Centers (INC) maintains a data warehouse and tracks consensus based clinical and financial national data on NMHCs as well as evaluating outcomes of care in these centers.

Program Description

National Nursing Centers Consortium (NNCC) is a national network of over 200 Nurse-Managed Health Centers (NMHCs)nationwide, many of them associated with schools of nursing, serving 2.5 million patients across the U.S. They provide accessible affordable quality health care and critical health services to underserved populations while also educating nurses and nurse practitioners for the future. NMHCs seek to strengthen the capacity, growth and development ofNMHCs to provide quality care to vulnerable populations and to eliminate health disparities in underserved communities.According to the Centers for Medicare and Medicaid Services evaluation, NMHCs meet the criteria for safety-net providers, as defined by the Institute of Medicine and an essential part of the health care safety net in the U.S.

Evidence of Success

• Produces equal or better outcomes at equal or lower costs when compared with health outcomes and costs in the aggregate.
• Have higher rates of generic medication fills, and lower rates of hospitalization than similar providers.
• Published findings regularly
• Called on for consultation and advice from NMHCs as well as state and federal policy makers
  

Harriet Kitzman, PhD, RN, FAAN
David Olds, PhD
Elly Yost, Director of Nursing Practice
Shannon Carstens, Marking and Communications Manager

Background and Goal

Every year, more than 800,000 children are born first-time mothers living in poverty. Without intervention, these births all too often lead to a pattern that is destructive for both the mother and the child. The mother feels trapped in her situation and gives up on continuing her education or finding a good job. The child grows up without a role model to show a way out of poverty and in a culture that encourages repetition of the cycle.
Nurse-Family Partnership’s goal is to help parents in targeted communities give their children a better start by providing care in the home, via a registered nurse, from pregnancy through the child’s first two years of life – to improve pregnancy outcomes, child health and development, and the economic self-sufficiency of the family.

Program Description

Nurse-Family Partnerships (NFP) is an evidence-based nurse home visitation program that improves the health, well-being and self sufficiency of low-income, first-time parents and their children. Nurse home visitors and their clients make a 2 ½ year commitment to the program, with 14 visits planned during pregnancy, 28 during infancy and 22 during the toddler stage.Nurse home visitor case loads do not exceed 25 families, due to the high level of complexities and health risks of the families served.

Evidence of Success

• 79% reduction in preterm delivery for women who smoke; 35% fewer hypertensive disorders of pregnancy; and a decrease insmoking.
• 39% fewer injuries among children, including a 56% reduction in emergency visits for accidents and poisonings from birth to age 2, and a 32% reduction in emergency visits in the second year of life.
• The Washington State Institute for Public Policy found that the program had the highest return on investment among all home visiting and child welfare programs evaluated, with a net benefit to society of $17,180 (in 2003 dollars) per family served, which equates to a $2.88 return per dollar invested in NFP.
• For the higher-risk families now served by the program, a 2005 RAND Corporation analysis found a net benefit to society of $34,148 (in 2003 dollars) per family served, with the bulk of the savings accruing to government, which equates to a $5.70 return per dollar invested in NFP.
• The New York City Department of Health and Mental Hygiene projected the expected cost savings to the city per 100 families served by the program, based on the published programmatic outcomes. The estimates are based on the cost of services that would not be needed as NFP achieves its intended positive effects and include:
  • 35 % reduction in pregnancy-induced hypertension: 3.5 fewer cases, saving $29,500;
  • 50 % reduction in child abuse and neglect, 0-2 years: 2 fewer cases, saving $38,500;
  • 35 % reduction in emergency room visits overall, 56 % reduction in emergency room visits for accidents and poisonings: 16.8 fewer visits, saving $11,584;
  • 50 % decrease in language delays at 21 months: 8 fewer children, saving $133,000-$440,000.
    

Mattia J. Gilmartin, PhD, RN, FAAN

Background and Goal

The major healthcare challenge addressed by Nurses Improve Care for Healthsystems Elders (NICHE) has been the need for evidence-based knowledge in the nursing care of older adults. Older adults are the largest consumers of hospital care, accounting for 17% of all hospital admissions.

NICHE has successfully developed this knowledge by pioneering the development of geriatric nursing clinical protocols, and most importantly, has developed a sustainable model for knowledge transfer across multiple healthcare delivery systems with nursing staff at all levels of practice encompassing CNAs, LPNs, RNs, APRNs.

NICHE transforms the organizational environment by adjusting staffing patterns and the physical environment to reduce preventable institutionally-acquired complications of delirium, falls, skin injuries, and functional decline among older adults. These iatrogenic complications are costly; reducing them isthe focus of national quality initiatives.

NICHE pioneered the development of evidence-based practice by nurses at the bedside. In the 1990s, NICHE leaders marshaled the evidence of the emerging field of geriatric nursing and packaged this knowledge in an accessible format for use by clinical nurses.

Program Description

NICHE focuses on the care of adults, aged 65 and older, by improving systems of nursing care for this population. NICHE is an evidence-based, organizational intervention led by nurses to deliver high-quality, safe, and reliable geriatric care during hospitalization and skilled nursing admissions.

NICHE closes the documented gaps in the knowledge and competencies of the nursing workforce to meet the health needs the population of older adults(numbering 54 million in the US), by offering continuing education for nurses employed in hospital and skilled nursing facilities (SNFs) to develop expertise in geriatrics. NICHE advances nurses’ position and contributions within interdisciplinary care teams that are required to deliver effective geriatric care. The Geriatric Resource Nurse (GRN) and Geriatric Nursing Assistant (GNA) roles are the hallmark of the NICHE model. These unit-based leadership roles support a culture of care focused on identifying and managing geriatric syndromes during periods of acute illness, rehabilitation, and long-term care.

The NICHE model integrates four mutually reinforcing elements:

• The Geriatric Resource Nurse (GRN) role to advance clinical specialization in geriatrics, unit leadership, and evidence-based practice.GRNs are peer mentors, coaches, and agents of change on their units who work to create an environment that promotes optimal care of older adults.
• Nurse-initiated protocols to manage the geriatric syndromes, iatrogenic events, and harmful sequelae of hospitalization.
• A physical environment and culture of care that honors older adults’ self-determination and promotes quality, safety, and function.
• Nurse-led care transitions that emphasize interprofessional care planning; preparation for patients and family caregivers; and complex symptom management.

Evidence of Success

In the past three years, more than 40,000 nurses working in 400+ NICHE member hospitals and SNFs have completed continuing education to prepare them for the GRN role. In 2020, NICHE offered more than 100 hours of continuing education programming to 57,951 participants who completed the Leadership Training Program, the GRN and GCNA courses, or webinar series.

NICHE has been adopted by nearly 10% of US hospitals, which in turn care for an estimated 1.5 million older adults annually. NICHE is designed to meet consumer, payor, and societal expectations for quality, value and improvements in health and quality of life.

The 2019 review of forty-three empirical studies by Squires et al. concludes that the NICHE practice model is significantly associated with improvements in clinical outcomes aligned with national quality measures including fall prevention and reduction; appropriate medication prescribing; dementia symptom management; delirium care; reduced catheter acquired urinary infections (CAUTIs); and expansion of advanced care planning services.

Program Description

On Lok is a network of centers combined with clinics and day services programs for seniors that provides comprehensive medical (acute, rehab and long term care) and health care, prescription drugs, bilingual case management, home-cooked meals and opportunities to socialize to more than 1,000 elders in multiple San Francisco and Bay Area locations. An interdisciplinary team of physicians, nurses, physical and occupational therapists, social workers, dietitians, recreational therapists, home care and health workers, and drivers formulates, coordinates and provides the services and activities.

Evidence of Success

Cost of care has been cited as being 15% lower than under the traditional fee-for-service care system. On Lok has had no cost overruns and has been able to self-insure for future needs.

Continued Impact of PACE Program - National PACE Association (2011):

• Rural PACE® Provider Grant Program - Report to Congress CMS has issued a Report to Congress on the evaluation of the Rural PACE Provider Grant Program. Congress encouraged the expansion of PACE into rural communities by authorizing the rural PACE provider grant program in section 5302 of the Deficit Reduction
  Act of 2005. The reports finds overall favorable experience by the rural PACE pilot sites, as well as their beneficiaries and communities, in the early phases of implementation.
• Study Cites Reasons for PACE® Effectiveness PACE® was one of three programs researchers identified as models of long term care that are effective, efficient and less expensive than traditional long term care in a study whose findings appear in the November 3, 2010 issue of the Journal of the American Medical Association ( JAMA).
• NPA Testifies at U.S. House Energy and Commerce Hearing on Dual-eligible Beneficiaries June 2011
• Shawn Bloom, NPA President and CEO, testified at a June 21 hearing organized by the U.S. House Energy and Commerce Subcommittee on Health, entitled, “Dual-Eligibles: Understanding this Vulnerable Population and How to Improve Their Care.” NPA was invited because of PACE organizations’ reputation for excellence and experience with serving the frailest subset of the duals: older adults requiring nursing home level of care.

Background and Goal

Even top schools cannot adequately prepare nurses for the challenges of today’s hospitals because of the patient acuity and the complex and increasingly technological hospital environments. Turnover rates among new graduates have ranged up to 50%.

The residency goal is to help baccalaureate program graduates transition from advanced beginner nurses to competent professionals in the clinical environment by providing clinical leadership and formulating an individual development plan for each nurse’s new clinical role.

Program Description

The nurse residency is a one-year transition-into-practice educational program that prepares new baccalaureate nursing graduates for their first professional registered nurse positions in acute care hospitals. It is based on the “Essentials of Baccalaureate Education” so the residency does not repeat education already provided in the baccalaureate degree. The curriculum is evidence-based, drawing on the research that defines the competencies, knowledge and experiences new graduate’s need beyond those obtained in their baccalaureate programs. Students are immersed in clinical work with a clinical preceptor who has attended training based on the national residency curriculum. Residents receive specialty training targeted to their clinical service such as a critical care course, a fetal monitoring course, etc. During the final six months of the program, residents receive content on selecting a mentor and constructing a career plan for their own development. Residents conduct an evidence-based project and present the project in a poster format.

Evidence of Success

• When the program began in 2002, some UHC hospitals reported retention rates for new graduates as low as 50%.The program has resulted in consistently high retention rates and in 2010, the program reached an aggregate retention rate of 96.1%.
• Program data from 2010 continues to show positive changes in overall competence and confidence. Resident scores have consistently improved in the organizing and prioritizing scales and the communication and leadership scales. Stress scores decrease significantly by the end of the residency.
• Improved commitment to the nursing profession is observed at the conclusion of the residency program, rated in 2010 by residents at 3.49 on a four-point scale.
• Average cost of replacing a new graduate RN is reported to be more than $80,000. Organizations have been able to document significant return on investment. A 2007 article in Nursing Economics detailed an organization with a 50% turnover rate that achieved a cost savings of $823,680 from implementing the nurse residency.
• To date in 2011, there are 81 hospitals participating in the residency and 25,000 residents have completed the residency.
• Post baccalaureate nurse residency accreditation standards were developed. CCNE has accredited 5 UHC/ACCN sites in 2010/2011 and three other sites have scheduled on-site evaluations.

Background and Goal

Mechanically ventilated critically ill adults, whether resulting from planned, urgent or emergent intubation, are at high risk for many healthcare acquired infections, particularly ventilator-associated pneumonia (VAP). Prior to Dr. Munro’s research, Oral Care in Mechanically Ventilated Adults, one in four patients who were mechanically ventilated in the ICU developed VAP, with 25% to 75% dying as a result.

Mechanically ventilated patients in the ICU are dependent upon nurses for many self-care activities, including oral care. However, despite the fact that oral care was a standard component of care for mechanically ventilated patients, there was little evidence to judge the benefits or associated risks of oral care.Prior research to reduce VAP included oral or systemic administration of prophylactic antibiotics, but these methods were necessarily limited due to the threat of increased antibiotic resistance in ICU’s. Dr. Munro’s project, Oral Care in Mechanically Ventilated Adults, focused research on the long-term goal of providing definitive guidance for effective evidence-based oral care interventions to reduce VAP and other healthcare acquired infections.

Program Description

With continuous NIH funding, Dr. Munro conducted three sequential randomized controlled clinical trials (RCTs), with the third currently underway.Dr. Munro’s first RCT examined the effects on dental plaque and risk of VAP with tooth brushing and chlorhexidine application, alone and in combination. The results of this RCT revealed that ventilated patients who received .12% solution chlorhexidine oral swab twice daily had significantly reduced incidence of pneumonia, but that tooth brushing neither reduced the risk of VAP nor enhanced the effect of chlorhexidine.

Dr. Munro’s second RCT more closely scrutinized the role of chlorhexidine to determine if adding a pre-intubation application of chlorhexidine further reduced the risk of VAP. The study revealed that pre-intubation application of chlorhexidine did not reduce the VAP risk beyond that afforded by the post-intubation application guidelines, an important finding permitting providers to forego pre-intubation chlorhexidine application for other critical pre-intubation activities that may yield benefits to the patient.

Currently, Dr. Munro is conducting a large RCT to determine the optimal frequency of tooth brushing for critically ill, mechanically ventilated patients in order to maximize oral health benefits such as control of mucosal inflammation and dental plaque, while minimizing systemic risks, including healthcare-acquired infections and inflammation.

Evidence of Success

• Dr. Munro’s finding that chlorhexidine reduced the risk of VAP was published in September of 2009 and, soon thereafter, in May of 2010, her findings were referenced by the Institute for Healthcare Improvement (IHI) in its updated national recommendations for the care of mechanically ventilated patients (the ventilator bundle), and now the CDC, to include daily oral care with chlorhexidine. By finding that swabbing the mouth with chlorhexidine every 12 hours following intubation suppresses the growth of potential VAP pathogens in the mouth and reduces VAP risk, Dr. Munro’s research provided specific evidence-based guidance for the common nursing intervention of oral care in mechanically ventilated adults.
• Dr. Munro’s first RCT revealed VAP rates 28% lower in patients who received chlorhexidine as compared to those who did not.
• Over the past decade, rates of VAP have fallen significantly, to an estimated current 5% of mechanically ventilated patients, as a result of concerted attention to VAP prevention, including a prominent focus on science based oral care practices.
• With each episode of VAP estimated to cost an additional $5000 in hospital costs, extrapolating Dr. Munro’s first RCT findings of a 28% reduction in the rates of VAP to the 1.7 million mechanically ventilated patients nationally each year, evidenced-based oral care every 12 hours with chlorhexidine could yield a savings of $2 billion annually.
  

Background and Goal

The connection between oral health and its relation to overall health is a major public health problem that has gone virtually unnoticed in the professional clinical education and practice of nurses, nurse practitioners, midwives, and their interprofessional colleagues. Oral health all too often remains a domain for the professional preparation of dentists and dental hygienists, disconnecting the mouth from the rest of the body as an integral dimension of overall health. Yet data show a high incidence and prevalence of dental caries(cavities), specially in lower socioeconomic and minority group. Adults and children are twice as likely to make at least one visit to an ambulatory care provider in a year as they are to a dentist. This highlights the compelling need to mobilize the nursing workforce to play a critical role in promoting oral health.This will lead to preventing dental disease and avoiding the systemic effects of poor oral health on acute and chronic health problems by integrating it as a required clinical education competency and standard of care.

Program Description

The Oral Health Nursing Education and Practice (OHNEP) Program is an innovative national initiative led by Executive Director Judith Haber, Program Director Erin Hartnett, and Program Coordinator, Jessamin Cipollina, who have cultivated a national network of faculty, clinicians, and organization champions who advance this critical population health issue, oral health and its links to overall health, in both academic and clinical settings.

The OHNEP Program, a core partner of the National Interprofessional Initiative on Oral Health (NIIOH), was funded in 2011 by the DentaQuest and Arcora Foundations, to answer the challenge for all health professions to “view the mouth as a window to the whole body” by linking oral health with overall health (HHS, 2000).

The OHNEP Program reminds faculty, preceptors, students, and clinicians in the nursing profession of the importance of oral health through professional development, curriculum integration, and establishment of best practices in primary, acute, community and long-term care clinical settings so that oral health and its links to overall health is an essential component of comprehensive whole person care (Haber et al., 2015; Interprofessional Education Collaborative, 2016; PCPCC, 2017). The OHNEP Model advocates use of a “weave approach” for integrating oral health into already crowded curricula and clinical practice settings by “weaving” oral health content into existing courses as it relates to a particular course focus. This is an effective strategy to overcome barriers to oral health integration including, but limited to: faculty expertise, competing priorities, and resources (Dolce, Haber, Savageau, Hartnett, & Riedy, 2018; Haber et al., 2019).

The OHNEP team also developed an oral health product in collaboration with GoMo Health. It is an oncology oral care outpatient digital therapeutic that is being integrated into the existing GoMo Health Oncology Digital Therapeutic so that oral health will play an important role in closing the gap in whole person oncology outpatient care.

Evidence of Success

OHNEP website outcome data for 2014-2018 reveal 18,233 users, 56,413 page views, 24,389, sessions, and 6,922 Interprofessional Oral Health Faculty Toolkit page views.

National survey data reveal that more than 50% of the 498 primary care nurse practitioner and midwifery programs nationwide are integrating oral health content and/or clinical experiences in graduate program curricula.

Background and Goal

In the US, the number of perinatal women with a substance use disorder (primarily opioid) has dramatically increased over the past decade and continues to escalate. The Appalachia region, and Kentucky in particular, lead the nation in perinatal substance use disorders (SUDs). This epidemic has profound immediate and lifelong maternal and child health implications, including neonatal abstinence disorder. However, the majority of pregnant women are unable to access essential services and private Medication AssistedTreatment (MAT) clinics often have long wait lists with cost-prohibitive feeds.

Thus, a multifaceted, interdisciplinary and collaborative approach is critical to addressing the complexities of treatment and support services for individuals addicted to opioids during pregnancy. Nurses are foundational in providing the"vision" and the "glue" to create, operationalize and sustain comprehensive treatment and support for these deserving women and their families. Currently,PATHways and Beyond Birth programming is reaching 38 of the 100-low resource, high need KY counties.

Program Description

PATHways and Beyond Birth are innovative programs provide comprehensive, trauma informed wrap around support to women with SUD and their children, provided by nursing, social work, obstetrics, psychiatry, behavior health, pediatrics, family practice and hepatology. This model’s innovative approach of effective transdisciplinary collaboration is the key component that has allowed the programs to become sustainable. Beyond Birth is within the University of Kentucky Supportive Mental Health and Addiction Recovery Treatment program (SMART Clinic).

The model also goes beyond perinatal treatment, with Beyond Birth providing services up to 5 years after birth. The perinatal nurse facilitator and peer support team is the ‘’primary glue’ to the program. This team leads weekly perinatal education and addiction recovery sessions, provides trauma-informed individual counseling, referrals to community resources to improve their access and to safe housing, and job training and/or secondary education all while coordinating a peer-mentoring program with participants who has successfully maintained recovery for 12 months.

PATHways and Beyond Birth are two partner programs that were developed and created with an interdisciplinary team of healthcare professionals and led by the University of Kentucky (UK) College of Nursing, Perinatal Research andWellness Center team in collaboration with UK Department of Maternal-Fetal Medicine and Psychiatry. From 2013-2020, Federal, State and University funding and private funding provided an infrastructure to create the PATHways and Beyond Birth programs for perinatal women with SUD. To date, these successful and sustainable programs continue to provide comprehensive treatment and support services to perinatal women despite grant funding ending due to unique partnerships.

Evidence of Success

When compared to a matched cohort of women prior to and after implementation, women in PATHways carried their infants longer gestation (p =.035), and their babies were less likely to experience NAS (p<.001). Further, the nurse facilitator-peer sessions were the only component of PATHways that significantly impacted relapse rates (e.g. for every one additional session increase, women were 15% less likely to relapse).

In a comparison study of 64 NICU/NACU infants whose mother’s participated in PATHWAYS, only 2 infants required medication for NAS compared to 12 of those that were not. Further, PATHWAYS infants had a length of stay 7 days shorter than those not enrolled in the program.

PATHWAYS and Beyond Birth have served over 600 perinatal women in the past 7 years.

Background and Goal

Pressure ulcers, or bedsores, are painful and potentially life-threatening injuries that can develop when people rest on one part of the body for too long. As of October 2008, Medicare no longer pays hospitals to treat bed sores and several other preventable problems that develop after hospitalization. Some private insurers are following Medicare’s lead. Annual treatment costs nationwide are estimated at up to $1.5 billion, with some studies showing the incidence of heel ulcers alone reaching more than 50% of surgical patients.

The Perioperative Pressure Ulcer Prevention Program (PPUPP) aims to drastically reduce the incidence of pressure ulcers in surgical patients through aggressive prevention methods.

Program Description

Perioperative Pressure Ulcer Prevention Program (PPUPP) is a program that covers staff education and awareness, assessment of environment and patient population served, skin and risk assessment, universal pressure precautions, equipment selection, positioning competencies, nurse specialty collaboration, quality improvement, and tracking of complications, care plans based on research. It supplements traditional methods to prevent pressure ulcer development (such as turning and repositioning) to incorporate new surfaces, padding, heel offloading devices, head cradles, and ulnar pads. It uses “ScottTriggers” – a set of evidence-based factors (named for nurse/ program founder Suzy Scott-Williams) identified as predictors of highest risk for pressure ulcer development in the study (e.g., age 62 or older, Albumin level below 3.5 and ASA score 3 or greater).

Evidence of Success

• In an experiment involving 323 patients between 2000 and 2004, 38% of patients who had the standard pad during surgery developed the sores. But only 7% of patients who had the pressure-relieving pad developed pressure ulcers.
• Over a five year period at the VA in Memphis – using 100% integrated air beds, and implementing a nursing protocol and tracking – the nosocomial pressure ulcer rate was dropped by 65%, saving more than $3.4 million on care.
• In the case of hip or knee replacement – common surgeries for Medicare patients – Medicare pays hospitals $10,300 for the surgery itself but has paid up to an additional $3,500 to treat pressure ulcers or other complications. Now that Medicare will not provide additional payment to treat pressure ulcers, a hospital where 4,000 patients suffer from the ulcers each year could lose $14 million on treatment.
• In addition to these reimbursement issues, other savings factors include:
  
  • Risk of litigation which is ranging from around $250,000 to $1 million per verdict
  • Cost of treatment $50,000 - $70,000 to heal a full thickness ulcer
  • Risk of infections and death
  • Increased length of stay
    

Marilyn J. Rantz, PhD, RN, FAAN

Background and Goal

Of the nearly 40 million persons 65 years of age or older in the United States, about 1.7 million live in nursing homes, a figure which is projected to grow to more than 5 million in 2030. Nursing home residents are among the frailest elders in our country, with major limitations in activities of daily living, multiple chronic illnesses, major limitations in mobility, and necessary 24 hour oversight by professional nurses and nursing staff to assist them in meeting basic goals. Seniors and their families seek high quality nursing home care where staff members use the most up-to-date, evidence-based care practices.Simultaneously, states seek to provide high quality care at reduced costs. TheQuality Improvement Program for Missouri (QIPMO) assists families and States in achieving both missions.

QIPMO aims to disseminate evidence-based best practices into mainstream clinical care in Missouri nursing homes. Through on-site clinical consultations,RN’s with graduate education in gerontological nursing provide role-modeling, analysis of care systems, guidance, team building, and knowledge transfer. QIPMO reaches out to all nursing homes in the state to improve care delivery and outcomes.

Program Description

When initiated in 1999, QIPMO was the first official state program of its kind in the United States. QIPMO is a cooperative service of the University of Missouri’sSinclair School of Nursing under contract with the Missouri Department of Health and Senior Services. It is funded by the Nursing Facility Quality of Care fund, established to provide training and technical assistance to facilities.

QIPMO provides free on-site clinical consultation comparing each facility to others in the state using Minimum Data Set (MDS) data. These confidential site visits (data are not shared with state regulators) typically last 2 to 3 hours and focus on quality of care, evidence-based practices, and quality improvement using quality measures (QMs) derived from the MDS data for monitoring progress toward care improvements. In 2011, the QIPMO program expanded to include a Leadership Coaching Service provided by experts licensed as nursing home administrators. Nursing homes receive consultation on issues such as corporate compliance, budget analysis, regulations, process improvement, leadership skills, staff training and retention, contract review, survey readiness, and culture change. Coaching is tailored to meet administrator needs within the context of operational situations as well as the corporate and business models in Missouri. The most frequent educational requests from nursing homes to QIPMO are for help in explaining and understanding how to interpret and use federal or state quality indicator/quality measure reports and survey readiness preparation. As evidence of the demand for QIPMO services, in 2015 nursing home visits totaled 878 for QIPMO nurses and 443 for QIPMO coaches. QIPMO is connected to most facilities in the state via email, telephone and fax, and maintains a web site with training materials that can be downloaded for free and helpful links (www.nursinghomehelp.org). In addition to disseminating evidence-based guidelines and practices, QIPMO also disseminates the latest research results provided by on-going research from the MU and MDS and Quality Research team.

Evidence of Success

• Clinical outcomes that improved in the early years of the program include scores at the median, 90th and 95th percentiles, in such things as pressure ulcers for high and low risk residents, range of motion or activities of daily living, dehydration, fecal impaction, residents remaining in bed, depression, depression with no treatment, problem behaviors, cognitive impairment, incontinence without a toileting plan, antianxiety, and hypnotic drug use. (Rantz et al., 2003).
• Clinical outcomes that improved in the later years of the program include five QIs with improved trends of 4% to 41% in important clinical problems of pressure ulcers, pressure ulcers for high-risk residents, weight loss, bedfast residents, and falls. Five other indicators also improved 2.5% to 20.7%, including important clinical problems of incontinence, incontinence for low-risk residents, urinary tract infections, depression, and use of physical restraints. (Rantz et al., 2009).
• A cost analysis performed from July 2007-June 2008 revealed that 990 residents avoided the development of expensive, debilitating problems at a care cost savings of over $4.7 million (Medical News Today, 2009). This followed cost savings from the 2006/2007 period of $1.5 million dollars from the facility at-risk group (n=60) and $1.6 million from the 2005/2006 annual period from the facility at-risk group (n=45) (Rantz et al., 2009).
  

Background and Goal

Farm operators experience frequent exposure to high noise and have among the highest prevalence rates of hearing loss across all categories of workers. The USDA estimates there are approximately 3,281,000 farm operators in the United States, with an additional 2 million children who either work on or visit farms also having an increased prevalence of noise-induced hearing loss due to farm noise. Most farms in the US are small, family run businesses which are neither served by labor organizations nor protected by the OSHA Hearing Conservation Standard.

Noise-induced hearing loss is permanent and irreversible, with treatment limited to hearing aids for sound amplification. In addition to hearing loss, noise exposure results in other serious and widespread health problems including elevated blood pressure and heart rate, increased risk of cardiovascular disease, increased risk of acute myocardial infarction, increased stress hormone levels, increased depression, and increased fatigue and tension. Noise exposure is particularly harmful to children and is linked to problems including decreased reading skills and memory, poorer school performance, increased distractibility, annoyance, and aggression. Noise-induced hearing loss is estimated to be the most common occupational disease in the US, costing the average person $12,000/year and the US $242 million annually on compensations for workers’ hearing disability. The collective monetary cost of untreated hearing loss is believed to exceed $100 billion annually.

The goal of Dr. Marjorie McCullagh’s intervention, Quiet4Healthy Farm, is to promote health and improve the quality of life among farm operators and farm youth by eliminating work-related hazardous noise exposures.

Program Description

Quiet4Healthy Farm is a collection of interventions from two programs, HEAR on the Farm and Hearing Heroes, designed and developed by Marjorie McCullagh, PhD, RN, APHN-BC, COHN-S, FAAOHN, FAAN, of the University of Michigan School of Nursing, and her team in consultation with farm operators and farm youth over several decades. These hearing conservation interventions include a number of features and techniques designed to promote behavior change. In contrast to the limited diagnosis and treatment practices of the past, Dr. McCullagh’s interventions present broad based preventive strategies (turn it down, walk away, and wear hearing protection) and are readily available to the farming population through face-to-face, mail, or Web-based formats. The highly interactive and predictor-based programs use multiple tools such as farmer-to-farmer communication, role modeling, cognitive strategies, videos, persuasive techniques, and animations of hearing physiology to increase farmers’ self-determination in changing their behaviors to prevent noise-induced hearing loss and noise associated health problems. Outcomes are measured using scientifically based instruments.

Evidence of Success

Strong Quiet4Healthy Farms has succeeded in reaching and changing the behaviors of a highly dispersed and often remote at-risk population. Dr. McCullagh’s partnerships with well-established farm organizations and institutions of higher education such as the American Farm Bureau, the Progressive Agriculture Foundation, and the University of Iowa have resulted in her interventions being used to inform national and state farm organization policies and programs, being adopted in standard curriculum reaching over 100,000 people in 338 US communities annually, and being included in a smartphone app for noise monitoring and education of farmers. Additional opportunities to provide farm operators, farm youth, and their family members access to Dr. McCullagh’s interventions at no cost are in development, including access through the sharing of a URL. Dr. McCullagh’s interventions have demonstrated sustained effectiveness over a 12 month period in increasing the use of hearing conservation strategies. U.S. analysis of economic burden of noise on cardiovascular disease suggests that even a modest 5-dB reduction in noise would reduce the prevalence of hypertension by 1.4% and coronary heart disease by 1.8%, resulting in an annual economic benefit of approximately $3.9 billion.

Background and Goal

As many as 50% of mothers of infants and toddlers who face economic hardship, resource challenges in rural America, impoverished urban neighborhoods or immigrant struggles have significant levels of depressive symptoms. For these mothers who confront multiple risks, the prevalence of significant levels of depressive symptoms rises to 64%. Since infancy and toddlerhood is the period when the most rapid brain and neuro-cognitive growth occurs, significant levels of depressive symptoms in a mother may compromise essential maternal functions and place the infant/toddler at risk for developmental and language delays, cognitive deficits and later school failure. Dr. Beeber and her multidisciplinary colleagues set out to produce, test and disseminate stigma-free, culturally tailored nursing interventions to reduce maternal depressive symptoms and enhance parenting to prevent negative child outcomes. Dr. Beeber’s program,
Reducing Depressive Symptoms and Enhancing Parenting in Low-Income and Newly-Immigrated Mothers of Infants and Toddlers, achieved its goal through the talent and ingenuity of advanced practice psychiatric mental health nurses delivering culturally tailored and, when needed, linguistically appropriate (Spanish) interventions.

Program Description

Dr. Beeber’s research teams conducted over 20 years of sustained research to identify how context-specific maternal stressors such as economic hardship, immigration, discrimination or child developmental disabilities were linked to maternal depressive symptoms. Being one of the first researchers to recognize the mother-child dyad as an integral unit, Dr. Beeber developed nurse-delivered interventions to increase maternal self-efficacy through symptom monitoring and control, problem-focused strategies and improved parenting. Dr. Beeber’s interventions are tailored to embrace ethnic and cultural practices and variations in literacy and language proficiency. At the core of the intervention is Hildegard Peplau’s Interpersonal Theory of Nursing (ITN), which guides nurses to engage mothers in a therapeutic relationship. By partnering with trusted home visiting services, the program bypasses stigma and instrumental barriers of cost, transportation and safety. This innovative intervention approach reduces maternal depressive symptoms and capitalizes on the reduction of symptoms to introduce improved mothering interaction strategies.

Evidence of Success

In randomized clinical trials of mothers with significant levels of depressive symptoms at baseline, Dr. Beeber’s program achieved the following clinical outcomes:

• Spanish-speaking Latina mothers who received the intervention reduced their depressive symptoms below clinical threshold in less than 3 months compared to mothers receiving usual care services from Early Head Start;
• Low-income English-speaking mothers who received the intervention demonstrated more child-directed speech, stimulating play and positive involvement with their infant/toddler compared to mothers who received equal attention and a health education intervention;
• Six months after receiving the intervention, impoverished Spanish-speaking Latina mothers had more positive attitudes toward their child compared to mothers receiving usual care services from Early Head Start;
• Retention rates across these intervention studies ranged from 70-100% of mothers with moderate to severe depressive symptoms remaining in the intervention long enough to receive a clinically significant dose (70%) of sessions; this was significantly higher than previous trials with the same population.

A randomized clinical trial revealed significantly higher retention rates of Dr. Beeber’s in-home, nurse-delivered program than previous studies, thereby driving the cost-effectiveness of the program. In a comparison of in-home InterpersonalPsychotherapy (IPT) to outpatient Cognitive Behavioral Therapy (CBT) and psychotropic medication, in-home IPT was cost effective 95% and 78% of the time as compared to Cognitive Behavioral Therapy (CBT) and medications, respectively and had a 0.586 probability of being the cost-effective option relative to medication and in-office CBT.

Background and Goal

More than a decade of funded research to Dr. Kathryn Bowles’ interdisciplinary team revealed both a lack of standards and great variation in the referral decision making process of hospital discharge planners for older patients from acute care to post-acute care (PAC). With over 13 million older adults dependent on referral decisions made by discharge planners each year, many older adults were discharged home to self-care with multiple unmet needs and risk factors for poor outcomes. The Bowles’ team demonstrated that patients who needed post-acute care but didn’t receive it were readmitted five times more often than similarly situated patients who did receive post-acute care. Armed with this troubling data, Dr. Bowles’ team obtained NIH funding from the NationalInstitute of Nursing Research to build and test a solution.

The resulting nurse developed and designed Discharge Decision SupportSystem (D2S2) is transforming the way clinicians identify high-risk patients and make referral decisions about who needs post-acute care.

Program Description

Unlike most risk screening tools that rely on administrative data and medical diagnoses that lack acceptable sensitivity and specificity to accurately identify those at risk, the Discharge Decision Support System is an evidence-based six-item screening tool that uniquely focuses on the factors that influence the self-care ability of patients once they are discharged.

The D2S2 assesses factors that are highly predictive of a patient’s ability to perform self-care, including the availability of a caregiver. The system is built with “smart” technology that effectively learns from the patients, their situations, and the health care received to become more accurate over time. By more accurately assessing the PAC needs of older adults, the D2S2 improves patient care and reduces hospital costs from readmission, both in care and penalties. The algorithm has been successfully commercialized by RightCare Solutions, a software company co founded by Dr. Bowles.

Evidence of Success

The evidence supporting the effectiveness and benefits of the Discharge Decision Support System continues to grow:

• In three prospective studies with hospitalized older adults, patients who scored high on the D2S2 (indicating increased need for PAC) were significantly older, prescribed more medications, had more co-morbidity conditions, had more frequent doctor visits, and had more frequent hospital admissions in the preceding six months than patients who scored as low risk;
• In a pre-post study comparing patients in usual care (without D2S2) to patients using D2S2, the number of patients refusing post-acute care decreased significantly from 31% to 23%, suggesting clinicians offered referrals more appropriately resulting in more patients agreeing as to the need;
• Results published in Professional Case Management showed a 6% and 9% reduction in both 30 and 60 day readmission rates respectively when comparing usual care to D2S2 implementation; Both periods represent a 26% relative reduction in readmissions.
• An NINR funded study by the Small Business Innovation Research mechanism resulted in significantly fewer 30-day readmissions for high-risk patients from the control to experimental phases (22.2% to 9.4%, p<.05). Overall (combining high and low risk patients), the experimental phase achieved a 33% relative reduction in 30 day readmissions (13.1% to 8.8%) and sustained a 37% relative reduction at 60 days.

Background and Goal

Frail, elderly individuals are at risk for adverse health outcomes, hospitalizations and premature nursing home placement. Those still living at home but not qualifying for home health care via Medicare need higher care levels than typically provided through outpatient physician visits. Senior ASSIST’s goal is to help the frail elderly deal with multiple medical problems, cognitive impairment and the lack of support systems so that they can avoid hospitalizations and continue to live safely in their own homes.

Program Description

Senior ASSIST (Assisting Seniors to Stay Independent through Services and Teaching) is a program under which a geriatric-trained registered nurse care manager makes home visits for comprehensive assessments and follow-up care. It provides individualized, ongoing instruction in self-care, including how to take medications, home safety, nutrition and more. Nurses collaborate with physicians, report changes in condition, assess response to treatment and refer clients to other community resources to strengthen the support system.

Evidence of Success

• Client Satisfaction (1998-2010)
  • 97% would recommend the service to others
  • 91% were highly satisfied with their health care
  • 95% reported the nurse helped get services essential to staying in their homes
  • 93% said health care services were coordinated
  • 94% reported they were taught about medications and diet
  • 91% believed their health was improved through Senior ASSIST
• Physician Satisfaction (1998-2010)
  • 96% saw program as beneficial to their patients
  • 93% said the program helped patients appropriately enter and use the health care system
  • 80% found patients were better able to self-manage their care
• Cost Effectiveness (2000)
  • 63% decrease in hospitalizations
  • 46% decrease in ER visits
  • 62% dollar savings to the health care system
• Significant improvements in patient clinical health indicators: B/P, nutrition, weight, HgbA1c, overall risk level (2000)

Background and Goal

Older adults frequently deal with anxiety linked to memory lapses. The Behavioral Risk Factor Surveillance System survey found that 11% of Americans aged 45 and older reported subjective cognitive decline, but 54% of those who reported it had not consulted a health care professional (Taylor et al., 2018). SeniorWISE strives to improve memory skills and performance, and change the negative beliefs about cognitive aging of older adults and, in doing so, reduce their stress levels.

Program Description

Senior WISE (Wisdom Is Simply Exploration) is focused on modifying risk factors and developing interventions to improve the everyday memory function of older adults across the cognitive spectrum. Participants learn to deal with anxiety linked to memory lapses via the use of attention focusing, memory strategy training, repeated practice, relevant modeling by others like themselves, and realistic expectations about cognitive abilities with age. The intervention was designed for various environments where older adults live, recreate and work and it emphasizes maintenance of the instrumental activities of daily living, e.g., reading a prescription label and dialing the pharmacy to order a refill. Senior WISE was implemented in Cleveland, Ohio (1996 1998) with175 older adults; Central Texas (2001-2011) with 420 older adults; and Arkansas(2007 2011) with 114 older adults, and Austin, Texas with 133 octogenarians(2011-2012).

Evidence of Success

• Total per-person health care and long-term care payments in 2020 from all sources for Medicare beneficiaries with Alzheimer’s or other dementias were over three times as great as payments for other Medicare beneficiaries in the same age group; $52,481 per person for those with dementia compared with $14,976 per person for those without dementia. (Alzheimer’s Association. 2022 Alzheimer’s Disease Facts and Figures. Alzheimer’s Dement 2022,18)
• Senior WISE (by preserving the cognitive skills of 842 Senior WISE participants) and rendering higher, more costly levels of treatment unnecessary produced savings for care of $37,505 per patient over two years for a total of $31.6 million, If inflation adjusted to 2020 costs.
• Translation of obesity and cognitive research in Arkansas via senior centers. Centers for Disease Control (1R18 DP001145-01) $1.2 Million-Total costs (2007-2012).
• Better Way to Live at Home: Education, Resources and Supports for Older Adults. Community Innovations in Aging in Place Initiative funded through the Administration on Aging. Translated in public housing, Austin, Texas. Family Elder Care, $1.4 Million total costs (2009-2012).

Background and Goal

Tackling the health care challenge of patient provider communication among communication-impaired patients in acute-critical settings, the SPEACS-2 model provides nurses necessary training and a toolkit to eliminate misinterpretations and inequities created by communications barriers. Throughout the COVID-19pandemic, the issue of communication impairment during mechanical ventilation was highlighted on a global level. Missed communications of patient messages can result in incorrect or unnecessary treatments, such as over sedation or inappropriate pain medication, and cause exasperation among patients that can result in agitation and the dislodging of essential medical tubes and lines. Acknowledging the need to expand nurses’ capacity to assess and accommodate those with communication disabilities, the SPEACS-2 model provides readily available communication tools applicable in most hospital units or applied in a systematic and equitable manner.

Program Description

The foundation of the nurse-patient relationship is built upon effective communication. Efforts to support and enable patient-provider communication is necessary to improve equity within the health system. Based on the value that all patients have the right to communicate with providers to the fullest extent possible, the SPEACS-2 program’s overarching goals are to improve accuracy and ease of patient communication, increase patient-provider communication, increase patient participation in care, and ultimately, reduce patient anxiety, frustration, and sedation exposure.

With the development of an online course, clinical decision pathway (algorithm) for communication strategies, downloadable communications tools, and a list of augmentative and alternative communication supplies, nurses are supported to assess for communication impairment, patients’ needs, and how to intervene properly.

Evidence of Success

With implementation in over six ICU’s and two teaching hospitals in a RWJF Interdisciplinary Nursing Quality Research Initiative Study, nurse participants demonstrated significant increases in knowledge, satisfaction, and comfort in communicating with non-vocal mechanically ventilated patients. Since the start of the SPEACS-2 program delivery, approximately 1700 nurses and clinical instructors and 1200 nursing students have been trained.

Through online SPEACS-2 training, selected care facilities where the program was implemented showed lower levels of patient ratings of difficulty with communication with nurses during mechanical ventilation. The SPEACS and SPEACS-2 programs have shown improvements in nurse knowledge, patient participation, and time efficiency in assessing patients. Qualitative data show improvements in the ease of communication and in use of communication tools, access to more accurate communication with and less misinterpretation from caregivers with patients who are not communication impaired.

With the estimated cost of adverse medical events from the result of poor patient-provider communications and lack of access to assistive communication services exceeding over $29 billion, the SPEACS-2 program has the potential to impact and prevent adverse events due to missed and misunderstood patient communication. The cost of SPEACS-2 communication support materials is approximately $4-$20/patient, and training costs are minimal one time, 1-hour salary, and 1 continuing education unit. Significant savings may be found in improved care efficiency, out-weighing the program's costs.

Background and Goal

Chronically critically ill patients need comprehensive, coordinated holistic care that intensive care units often are not designed to provide.

The goal is to continue to provide needed technologic interventions, while also allowing nurses to focus on patients’ emotional and social needs and family needs through the use of nurse-managed “Special Care Units” as a companion to ICUs.

Program Description

A special care unit for the chronically critically ill is a unit that is physically separate from the regular intensive care unit. Nurse case management is the care delivery system, with medical care delivered by one attending pulmonologist. Patients are transferred to the SCU following a five-day stay in the ICU and remain in the SCU until discharge. It acknowledges that aggressive use of sophisticated technologies is not sufficient to restore an acceptable quality of health to patients who have experienced prolonged periods of critical illness. Instead, it is important to alter the environment, to provide a more balanced approach, tending to social and emotional needs, and explicitly re-evaluate goals of care. The program addresses physical care needs of critically ill patients as well as the psychological impact of critical illness –addressing coping, depression, and life satisfaction after critical illness.

Evidence of Success

Studies have shown a significant reduction in “cost per survivor,” (that is, effectiveness as measured by the total costs of the program and the number of patients successfully discharged from the hospital) as well as a reduction in early re-hospitalization rates, with no increase in mortality or complications.

Readmission rates to the hospital within three weeks of SCU care were 8%, compared with 20% where traditional ICU care was involved.

The average cost per survivor was $109,220 in the SCU, vs. $138,434 in the traditional ICU care.

Since the original trial of the Special Care Unit, hospital discharge patterns for chronically critically ill have changed markedly. The growth in long-term acute care facilities (LTACs) and expansion of the capacity of skilled nursing facilities to care for ventilator-dependent patients have enabled the chronically critically ill to be discharged directly from ICUs, thus reducing the demand for in hospital special care units. However, this trend created a new need to address the post-discharge care coordination and family support needs for this high risk, complex, and growing population. Responding to this, we conducted a trial of a post-discharge “Disease Management” program for CCI patients and their family caregivers. This program entailed follow-up and care coordination from an Advanced Practice Nurse for three months post-discharge, regardless of discharge destination. The program demonstrated a significant reduction in post-discharge days of re-hospitalization, associated with a significant reduction in cost (Daly et al, Chest 2005; 128: 507-517). Most recently, in response to findings from these previous studies of the very high risk of post-discharge mortality and long-term morbidity in this population, we designed an “intensive communication” intervention to assist family decision makers facing care decisions for their CCI loved one in the ICU (Lilly & Daly, NEJM 2007; 356: 513-14; Daly et al, Chest 2010; 138: 1340-48). We are continuing to investigate the phenomenon of decision making around goals of care for these long-stay ICU patients.

Background and Goal

After learning about multiple nurse suicides within her organization, JudyDavidson, DNP, RN, MCCM, FAAN, and her team discovered there was no recent research within the United States on the incidence of nurse suicide. The last time it had been studied was in the 1990s. Dr. Davidson and her team led a pilot study in San Diego, utilizing 10 years of medical examiner data, which found that nurses were at a higher risk of committing suicide than the general public.

This is especially pertinent in 2021 – two years into the COVID-19 pandemic.Nurses are seeing an unprecedented increase in the number of patients in dire condition and healthcare systems are being tested in ways they haven’t before.The incredible emotional toll of working through this period has amplified the need for nurse suicide intervention and a focus on mental health for nurses and healthcare providers.

The goals of the Nurse Suicide Prevention model are to shift nursing culture from solely focusing on caring for others to caring for ourselves as well, decreasing stigma surrounding nurses seeking mental health treatment through educational outreach, providing ‘in the moment care’ through group emotional debriefing after critical incidents, and proactively, anonymously identifying and referring nurses in need of treatment or at risk of suicide. These debriefings are interdisciplinary and all who have cared for a patient or were affected by an event are welcome. This support is integral to a team-based approach to healing and strengthens the caring community.

Program Description

The Suicide Prevention in Nursing: Breaking the Silence model is an evidence-based suicide prevention program for nurses, backed upon investigator-initiated research, to quantify incidence and characteristics of nurse suicide in the United States. By increasing education and outreach to dispel the stigma around mental health, the program advocates for better resources to support the mental health of nurses, which ultimately saves lives.

The Suicide Prevention in Nursing model was developed by an interprofessional team inspired by the novel research and the first national longitudinal study of U.S nurse suicide led by Judy E. Davidson, DNP, RN, MCCM, FAAN, Nurse Scientist at the University of California, San Diego Health Sciences (UC SanDiego Health). Dr. Davidson collaborated with her colleagues at UC San DiegoHealth; William Norcross, MD, Sidney Zisook, MD, Brittany Kirby, MSW, GiannaDeMichele, LMFT, Rachael Accardi, LCSW, Courtney Sanchez, LCSW, and JulieKawasaki, LCSW. The team was aware that a suicide prevention program, the Healer Education Assessment and Referral (HEAR), was launched at UC San Diego School of Medicine in 2009 for physicians and medical students but no program existed specifically for nurses. This spurred the initiative to include nurses and other non-physician healthcare workers.

The Nurse Suicide Prevention model utilizes an Interactive Screening Program (ISP). The ISP offers nurses a safe and confidential way to conduct a brief screening and connect with mental health services to receive support and access to treatment options – anonymously. The ISP is a licensed program of the American Foundation of Suicide Prevention. 

The main elements of the program are:

• A proactive screening program which can detect nurses with risk factors such as substance use disorder, depression, anxiety disorders, and suicidality;
• 1:1 bridge therapy that is anonymous and/or confidential without showing on participants’ medical records;
• Referral to mental health treatment, when indicated, which can be done while remaining anonymous;
• Group emotional process debriefings after significant workplace events, facilitated by specialized therapists; and
• Educational outreach.

Evidence of Success

In 2016, during the first year of the program’s launch, 40 nurses received counseling and 17 were successfully referred for continued treatment. Over a five-year period, between 2016 and 2020, Suicide Prevention in Nursing, has identified and transferred close to 300 nurses into treatment. In addition, over 1,000 nurses have benefited from group emotional process debriefings after critical events during its operation.

Since its launch, at least six organizations have replicated the program, using the American Foundation of Suicide Prevention ISP to screen nurses for suicide prevention. It is a cost-effective strategy to overcome the stigma of seeking help for mental health issues.

The National Suicide Prevention Lifeline is 1-800-273-8255. Other international suicide helplines can be found at befrienders.org.

Background and Goal

The health status of American Indian/Alaska Native and Indigenous youth globally is below that of the general youth population, with striking differences in areas including depression, suicide, anxiety, and substance abuse. The death rate for American Indian/Alaska Native youth is twice that for youth of other racial or ethnic backgrounds, and nearly 3 times higher for American Indian/Alaska Native boys. Early substance abuse is associated with antisocial behavior, conduct disorder, other mental health disorders, and school failure. While the economic costs of substance abuse to the American Indian/Alaska Native and Indigenous communities are significant, the human costs are even greater, with substance abuse and health-compromising behaviors during youth underlying many major causes of American Indian/Alaska Native and Indigenous morbidity and mortality.

American Indian/Alaska Native and Indigenous youth have the earliest age of initiation of alcohol use and the highest rates of binge drinking. By age 11, American Indian/Alaska Native and Indigenous youth are more likely than other youth to have initiated substance abuse and by the twelfth grade, 80% of American Indian/Alaska Native and Indigenous youth are active drinkers. In addition, American Indian/Alaska Native and Indigenous youth are more likely than other youth to have used methamphetamines, with a 6-fold increase in use in just the past 2 years. While current data on the rate of prescription drug abuse among American Indian/Alaska Native youth is limited, American Indian/Alaska Native as a population have significantly higher reported rates of non-medical prescription drug use. Dr. John Lowe, PhD, RN, FAAN developed Talking Circle Intervention for the prevention and early intervention of substance abuse and other health risk behaviors engaged in by American Indian/Alaska Native youth nationally and Indigenous youth internationally.

Program Description

The talking circle is a tradition among American Indian/Alaska Native and Indigenous people, and continues in practice today. Through use of this symbolic tradition, Dr. Lowe has enabled American Indian/Alaska Native and Indigenous youth to use the support and insight of each other to move away from harmful behaviors, such as substance abuse, and to move toward something positive. American Indian/Alaska Native and Indigenous people consider the whole greater than the sum of its parts and believe that healing and transformation should take place in the presence of a group since all people are related to one another in very basic ways. Each participant of the talking circles serves an important and necessary function that is valued no more or no less than any other being. Through the Talking Circle intervention, the traditional sense of belonging is fostered and participants experience healing or cleansing. Dr. Lowe has also developed and tested the Virtual Talking Circle intervention where, through the use of video-conferencing technology, the Talking Circle intervention is now being delivered to multiple American Indian/Alaska Native communities throughout the United States.

Evidence of Success

• The Talking Circle intervention is guided by a theoretical framework and model, Native-Reliance, and measured by the Native-Reliance Questionnaire.
• The outcome of implementing the Talking Circle (TC) as compared to Standard Education (SE) for substance abuse prevention and early intervention consistently demonstrates effectiveness for decreasing substance use involvement among various American Indian/Alaska Native and Indigenous populations, e.g. National Institute on Drug Abuse substance abuse scores between TC and SE groups were significantly different and there was a significant interaction effect between time and group.
• American Indian/Alaska Native and Indigenous communities where the Talking Circle intervention is being implemented are reporting a positive impact on their economies due to the decrease in costs associated with substance abuse.
• The Talking Circle intervention studies provide employment for people from local American Indian/Alaska Native and Indigenous communities.
• The use of technology to implement and deliver the Virtual Talking Circle intervention is enhancing education and economic development while preserving and strengthening American Indian/Alaska Native cultural traditions.
• The Talking Circle intervention has received recognition from the U.S. Department of Justice’s Office of Programs as an evidence-based program affecting juvenile well-being.
  

Background and Goal

Providing rural emergency medical care is often difficult because of limited resources and a scarcity of medical providers, including physicians trained in emergency medicine. Many rural emergency departments are challenged by a workforce shortage as well as financial constraints. Previous telemedicine models were not well designed to provide affordable care to unstable or potentially unstable patients.

The TelEmergency Program utilizes real time video streaming via T-1 lines and specially trained nurse practitioners in rural emergency rooms across the state in order to provide quality, affordable medical care to patients in rural emergency departments.

Program Description

TelEmergency, unlike many other telemedicine systems, provides real time, unscheduled emergency care to communities that need it the most. This system is available 24 hours a day, seven days a week for any type of consultation necessary for emergency room patients. Advance practice nurses provide emergency care in an affordable manner because the cost of a nurse practitioner is substantially less than contracted physician coverage. This program leverages the strength of nurse practitioners and is built around a multidisciplinary team. The result is high quality health care in areas that need it the most.

Evidence of Success

• Comparison of these rural hospitals’ operational data before and after implementation of the TelEmergency program reveal:
  • 25% reduction in staffing costs
  • 20.1% increase in local admissions
  • 10.9% increase in patient transfers to a hospital for a higher level of care
• Analysis of the program’s operation reveal:
  • Nearly 50% of all patients are evaluated collaboratively by the nurse practitioner and collaborating physician, while the remaining % of all patients were treated independently by the nurse practitioner.
  • 62% of patients are discharged from the ED at the rural site, while 18% are transferred to other hospitals for a higher level of care.
• A specially trained nurse practitioner and a board certified emergency physician are linked via the telemedicine system for approximately $53,000 per month for full time coverage is used in comparison to a physician, that is not specifically trained in emergency medicine, which would be approximately $72,000 per month for full time coverage. The only other additional cost incurred by the rural hospital is the T-1 line, which costs $527 per month. This is a savings of approximately $18,500 a month.
  
• Has trained more than 45 nurse practitioners, who have implemented the program in 15 hospitals and treated over 150,000 patients since its inception.

Background and Goal

Individuals with multiple chronic conditions experience significant challenges following hospitalization and require complex care management, especially during the post-discharge period. This is particularly true for the nearly 80 million individuals in the U.S. who are insured by Medicaid for whom post-discharge disparities are among the most common. Medicaid-insured adults are admitted to the hospital over 8 million times annually, and readmission rates for Medicaid-insured adults ages 45-64 are demonstrably high, at 24% compared to 20% for older adults and those with disabilities insured by Medicare. Similarly, about 34% of individuals insured by Medicaid will experience an emergency department (ED) visit annually, far exceeding the rates of those insured commercially. 

With incomes 138% below the Federal Poverty Level, readmissions and post-discharge from the emergency department are frequently attributed to social and economic determinants of health including financial stress, high out of pocket costs, and housing instability. Systemic factors, including inadequate discharge planning, poor care coordination, and a lack of access to community-based care complicate the transition to home. The THRIVE transitional care model was developed to support Medicaid-insured and dually eligible adults during this critical period following hospitalization and discharge to home. 

Program Description

The THRIVE transitional care model was created by an interprofessional team of researchers, clinicians, and community stakeholders to reduce disparities experienced by Medicaid-insured adults and address pervasive gaps in care. THRIVE redefines post-hospitalization care by focusing on holistic, patient-centered, and equitable approaches. THRIVE is a 30-day intervention that includes intensive wrap around services, home care, virtual case management and extended engagement of hospital-based providers following hospitalization. 

The model has three key pillars: proactive identification and referral, ongoing clinical supervision, and a comprehensive support network. Nurse Case Managers, using electronic health record flags, identify potential participants during discharge planning. Patients who agree to participate are referred to the THRIVE clinical pathway, ensuring a home care nurse visits within 48-72 hours post-discharge. For 30 days after discharge, THRIVE provides extended clinical supervision, including weekly case management calls and virtual case conferences, with hospital-based providers remaining available to support home care nurses until the patient sees their primary care provider. Additionally, weekly virtual interdisciplinary case conferences address chronic disease management and social determinants of health, ensuring holistic care. Participants are connected to primary care providers and community resources, including social work support for psychosocial and mental health needs. 

Evidence of Success

Since its implementation in April 2019, the THRIVE transitional care model has demonstrated significant improvements in clinical and financial outcomes: 

• Data published in BMJ Open Quality showed that Medicaid-insured adults who participated in THRIVE experienced fewer readmissions (14.3% vs 28.4%) and emergency department (ED) visits (14.3% vs 28.8%) compared to those who did not participate. These reductions in readmission and ED utilization metrics have persisted over the past five years, with over 1,000 patients discharged from Penn Presbyterian Medical Center receiving THRIVE support since publication. 
• Prior to the introduction of THRIVE, approximately 25% of Medicaid-insured adults were seen by a primary care provider. With the introduction of THRIVE services, over 85% of participants are seen by a primary or specialty care provider within 30 days of discharge.
• THRIVE aligns with health system value-based care initiatives, including readmission reduction programs and increasing access to resources, primary, and specialty care. Each hospital readmission is estimated to cost the health care system up to $15,000. By reducing 30-day readmissions by over 50% in its first year, THRIVE services have generated an estimated cost savings of over $225,000 per year. 

Since its launch at Penn Presbyterian Medical Center in 2019, THRIVE services have expanded to two other acute care settings, including Pennsylvania Hospital and the Hospital of the University of Pennsylvania (HUP)- Cedar campus. The model has been published in several high-impact peer reviewed journals and has received merit-based grants to develop and expand its reach. Notably, in 2022, THRIVE received the Learning Health System Interest Group Challenge Award for its distinguished contribution to equity, impact and outcomes for socially vulnerable patients. The model continues to demonstrate the importance of wraparound supports for Medicaid-insured adults at risk for experiencing health disparities during the critical transition from hospital to home. 

Contact Information

J. Margo Brooks Carthon, PhD, RN, FAAN, Professor, University of Pennsylvania
jmbrooks@nursing.upenn.edu 

Additional Contributors

Pamela Z. Cacchione, PhD, CRNP, BC, FGSA, FAAN, Nurse Scientist & Professor of Geropsychiatric Nursing, Penn Presbyterian Medical Center, University of Pennsylvania School of Nursing, pamelaca@nursing.upenn.edu

James Ballinghoff, DNP, MBA, RN, NEA-BC, Chief Nurse Executive, University of Pennsylvania Health System, James.Ballinghoff@pennmedicine.upenn.edu

Rebecca Clark, PhD, RN,MSN, CNM, WHNP-BC, Nurse Scientist & Associate Professor of Women’s Health and Midwifery, Pennsylvania Hospital, University of Pennsylvania School of Nursing, rrsclark@nursing.upenn.edu

Marsha Grantham-Murillo, RN, MSN, Associate Director of Community Programs and Diversity; Nurse Manager, Penn Medicine at Home, marsha.grantham-murillo@pennmedicine.upenn.edu

Regina Cunningham, PhD, RN, NEA-BC, FAAN, Chief Executive Officer, University of Pennsylvania Hospital Cedar Campus, regina.cunningham@pennmedicine.upenn.edu

Sebastian Ramagnano, RN, MSN, Associate Executive Hospital Director, University of Pennsylvania Hospital Cedar Campus, Sebastian.Ramagnano@pennmedicine.upenn.edu 

Background and Goal

Tobacco use is the leading cause of preventable death worldwide, contributing to significant suffering and disability. As the largest group of health care professionals, nurses have tremendous potential to effectively implement smoking cessation interventions and advance tobacco use reduction goals as proposed by Healthy People 2020. In 2003, Drs. Linda Sarna and Stella Aguinaga Bialous, Co-Principal Investigators, designed and implemented Tobacco Free Nurses (“TFN”) to support nurses in assisting patients with tobacco dependence treatment, translating evidence into practice, enhancing nurses’ involvement in tobacco control efforts nationally and internationally, and helping nurses and student nurses –who had a higher smoking rate than other health professionals – stop smoking.

Program Description

Working with nurse champions, nursing and health professional organizations, academic centers and other partners, TFN tested combinations of low-cost web-based interventions and print media to enhance nurses’ involvement in all aspects of tobacco control. TFN activities are housed on their award-winning website,
www.tobaccofreenurses.org. Since 2003, TFN has designed and implemented national and international projects which 1) provide tobacco cessation education to practicing nurse clinicians, 2) provide tobacco control resources for patient care, 3) support and assist smoking cessation efforts of nurses and nursing students and 4) enhance the culture of nurses as leaders and advocates of a tobacco free society. To translate evidence from the US Public Health Services’ Tobacco Dependence Treatment Guideline into practice,TFN developed a pocket guide, Helping Smokers Quit- A Guide for Clinicians, which has been one of the most widely requested print documents from the Agency for Healthcare Research & Quality, republished in many formats and translated into multiple languages.

Evidence of Success

TFN has been recognized by the World Health Organization as an exemplar of health professional advocacy in tobacco control. As of February 2017, over 6,000 nurses have formally participated in TFN educational and policy efforts in the United States and in eight other countries. If each of these 6,000 nurses advised only one patient/week to quit x 12 months for 4 years, 1.3 million smokers would have received support to make a quit attempt. Tobacco use costs $300 billion a year in the United States. Currently, 36.5 million adults continue to smoke. A 10% reduction in smoking rates would lead to 3.65 million ex-smokers, and a large reduction in costs, morbidity and mortality. The 3 million nurses nationwide could easily help make this a reality. Since TFN was launched in 2003, there has been a 36% decline in the prevalence of smoking among registered nurses, to an all-time low of 7% in 2011, as reported in JAMA as part of the issue celebrating the 50th anniversary of the US Surgeon General Report.

Ellen L. Brown, EdD, RN

Background and Goal

Depression in the home care setting is prevalent, often undetected and inadequately treated. Research has established that many home care nurses believe they are not adequately prepared to screen for depression, particularly among older patients. Failure to detect and adequately treat depression is associated with increased risk for nursing home admission, morbidity, and risk of suicide and mortality from other causes. Medical costs for depressed older adults are estimated to be 50% higher than for non-depressed elderly, including for home care recipients.

The Training in the Assessment of Depression assures that home health care nurses working with patients in their homes better identify symptoms of depression and direct patients to further evaluation.

Program Description

TRIAD is a training program for the approximately 120,000 home care nurses providing skilled nursing for more than 1million older adults yearly in the United States. TRIAD helps nurses, as well as social workers, physical therapists, speech therapists, and occupational therapists working in the home health care service sector, identify clinically meaningful depression symptoms and refer suspected cases. TRIAD is a two-prong intervention designed to (1) improve knowledge, attitudes, skills and motivation to detect geriatric depression and to refer suspected cases for further evaluation; and (2)modify, if not already in place, a home health care agency’s procedures to support depression detection and referral procedures.

Even when depression screening with standardized words are used (i.e., PHQ-2, GDS-15) nurses benefit from TRIAD given the medical complex status of these patients and nurse-identified need for more training. Further, patients often need a great deal of encouragement and support to follow through with appointments for mental issues that they may not feel are essential. The core educational TRIAD program consists of two sessions, one month apart, totaling 4 ½ hours. It is designed to be delivered by a nurse, psychologist, social worker, or medical doctor knowledgeable about geriatric depression and barriers to recognition and referral in the home care setting. A web-based version of TRIAD, including how to assess for suicidal ideation, and the Depression Tool Kit are now available.

TRIAD was developed by Brown, Martha L. Bruce, PhD, MPH, and their colleagues at the Weill Medical College of Cornell University following a series of studies that established depression in older adult home health care patients is prevalent and often remains undetected and inadequately untreated.

Evidence of Success

Clinical Outcomes: In 2007 a randomized trial among 53 home care nurses, the nurses who received the TRIAD were 2.5 times as likely to correctly identify depressed patients and refer them for further evaluation, following agency protocols, with the referrals leading to better clinical outcomes. There was no effect on unnecessary referrals for research-confirmed patients without depression (i.e., the intervention did not promote false-positive referrals).

Financial Outcomes: Based on a 2009 study of health care costs associated with depression in medically ill fee-for-service Medicare patients, national implementation of TRIAD – by at least doubling the number of depressive episodes recognized, referred, and treated – could save $10,000 per patient, by reducing outpatient and long-term care costs.

Background and Goal

Frontline nurses working in interprofessional teams in complex environments are poised to identify and implement processes to improve quality of care. Transforming Care at the Bedside (TCAB) cultivates leadership and provides tools to empower nurses to contribute to significantly transform the health care system.

Transforming Care at the Bedside – or TCAB – is a learning collaborative that engages nurses and other frontline healthcare staff in generating and testing ideas that can lead to practices and processes that are more consistent, efficient, safe, and patient-centered.

Program Description

Since 2003, when The Robert Wood Johnson Foundation and the Institute for Healthcare Improvement developed Transforming Care at the Bedside, the curriculum and training has been available to hospitals with many organizations embracing TCAB and spreading the process to other units and departments. In 2009, efforts were initiated to implement TCAB in a more concentrated way through regional and statewide efforts. By mid-2011, a total of 181 hospital teams in 7 regions across the country including, Maine, Minnesota, New Jersey, New York, New Mexico, Oregon, and Wisconsin, were actively participating TCAB.

The Regional approach employs a Regional Clinical Leader who is responsible for the management of the day-to-day TCAB activities, and supports the teams through monthly conference calls, coaching and site visits, and web-based resources. With the regional proximity, participating hospital teams can efficiently use their resources, promoting collaboration within the community. This model further reinforces sustainability and spread, with the supporting resources and knowledge accessible and existing within the region.

Evidence of Success

Hospitals involved in TCAB have improved patient safety through reducing medication errors.

• With the implementation of the medication safety zone, a hospital in Maine improved patient safety by decreasing medication errors in one year by 70% from 20 to 6.
• A Minnesota hospital decreased medication variations from 72% per month to 23% in just 2 months.

TCAB has spread beyond medical-surgical units.

• A hospital team in Wisconsin has spread TCAB collaboration beyond their pilot unit with involvement from Nutrition Services, Social Services, Physical Therapy, Occupational Therapy, and Respiratory Therapy.
• Maine’s Regional TCAB launch included a skilled nursing facility.
• One New Jersey TCAB team includes The Visiting Nurse Association of Central New Jersey with a 10-nurse team.

Many TCAB teams have focused on patient and family care and have improved their patient satisfaction scores. Examples as they relate to HCAHPS scores include:

• scores related to prompt staff response to call button increased from 40% to 90%;
• well-controlled pain score improved from 63% to 68.8%; and
• staff addressing pain score improved 70% to 81.3%.

Hospitals investing in TCAB have reported significant cost-savings.

• A Western New York hospital has experienced cost savings hospital-wide. Experiencing an increase in team vitality through TCAB, the TCAB unit maintained no nurse turnover for eight consecutive months. As a result, the hospital estimates cost savings of $240,372.
• Another hospital in Western New York hospital reported a 67% reduction of Hospital Acquired Pressure Ulcers, estimating cost savings of $880,000 - $1,540,000.
• Through the implementation of team admissions, one team in New Jersey reduced incidental overtime by 30 hours per month.

Background and Goal

According to Alzheimer’s Disease International, more than 46 million people worldwide have dementia. This number is estimated to increase to 131 million by 2050. In the US in 2017, an estimated 5.7 million Americans aged 65 and older were living with Alzheimer’s disease (AD). By 2050, the prevalence of AD in the US is expected to triple.

Though most Americans live without dementia, they often feel uninformed and fearful of the disease. One study found that 44% of Americans fear AD more than any other disease, including cancer, and 75% report not being knowledgeable about AD. Providing care for a family member with AD or a related dementia is not a role for which most are prepared, but one that they will likely have to play in the future. AD is a chronic condition, typically lasting 8to 10 years, during which the needs of people with dementia (PWD) change necessitating different management, services, and required ongoing care coordination. Accessing services and resources is a daunting task, and family and caregivers often struggle to meet the changing needs of PWD.

There have been numerous calls for initiatives to create infrastructure, programs, and policies to meet the needs of PWD and their families, most notably the CDC’s Healthy Brain Initiative. Nearly all of these plans include public health recommendations and strategies for increasing public awareness and early detection and diagnosis of dementia.

While there is clearly national momentum toward creating dementia-friendly communities through education and awareness, dementia information and caregiver support are fragmented and provided through various sources, including primary care physicians and national organization websites. Many older adults are unable to navigate complex health websites and struggle with reconciling information from diverse sources. Research also indicates a need for more coordination of health and social care provision for older adults, including utilizing care pathway technologies and creating technologies designed to be user-friendly for older adults (e.g., touch screens that are more usable than keyboards for older adults with arthritic hands).

Program Description

The Dementia Guide Expert mobile app is a unique centralized resource wherePWD and caregivers can find evidence-based expert information on what dementia is, types, contributing factors, risks, symptoms, stages, diagnosis, tests, treatment, management, communication techniques, and links to resources and support services. The Dementia Guide Expert mobile app thus serves as a unique resource that uses a dementia-positive approach to provide resources, tools, and interventions to support caregivers and care recipients as they confront the challenges of dementia.

The Dementia Guide Expert mobile app is free and user-friendly. It is currently available for download to iOS devices through the Apple App store and iTunes and to Android devices through Google Play.

Building on the success of the English version which had over 34,800downloads/views in 2.5 years, and upon user request, the app content was recently translated into Spanish and is currently being translated into Korean.The 5-year goal (funded by HRSA) is to translate the app into the most popular global languages (one new language each year): Chinese (Mandarin), Hindi/Urdu, Arabic, Malay, and Russian. This will help in global adoption of the Dementia Guide Expert mobile app, increasing dementia awareness and providing the world population with skills to better understand and manage the challenges of dementia.

Ultimately, the Dementia Guide Expert mobile app has the potential to create a dementia-friendly community on a global scale, one that is informed and better prepared for the challenges of dementia care through increasing public understanding and empathy for PWD.

Evidence of Success

The “Test Flight” app released to 20 clinicians for beta testing found that 50% strongly agreed and 50% agreed the app provided valuable information, offered practical advice, provided valuable resources, and was useful for people with dementia and caregivers. 67% agreed and 33% strongly agreed the pictures enhanced their experience and the text was sufficiently large.

This initial usability and functionality testing with community-dwelling older adults and clinicians led to improvements in the design and presentation of the content. The app was refined, and Prototype 14 of the Dementia Guide Expert was launched in December 2017. Since its launch in December 2017, the app has been downloaded/viewed over 34,000 times in 12 countries (Australia, Brazil, Canada, China, Germany, Japan, Korea, New Zealand, Spain, Taiwan, UK, and US). As previously mentioned, the app is available in Spanish, “Guia Experta Sobre La Demencia,” and both the English and Spanish versions are available for free download on iOS and Android devices.

Background and Goal

The National Center for Health Statistics estimates that about 64% of newborn boys undergo circumcision in the United States. Evaluation of current evidence by The American Academy of Pediatrics indicates that health benefits of newborn male circumcision outweigh the risks, thus supporting access to this procedure for families who choose it.

More than 5% of infants have been reported to require hospitalization to address a wide range of health conditions for a period of time immediately following birth. A challenge has long existed for infants born with medical comorbidities which preclude immediate newborn circumcision and for families who elect newborn circumcision following hospital discharge. Unless an infant had a circumcision performed in the immediate newborn period prior to hospital discharge, the only option in many healthcare settings has been to schedule the procedure at age 1 year or older in an operating room under general anesthesia. In 2017, the US Food and Drug Administration (FDA) recommended limiting exposure to general anesthesia in children younger than 3 years given evidence that cumulative anesthetic exposures may negatively affect brain development in children.

Additionally, surgical pre-procedure planning most often requires family caregivers to take additional time away from work and family responsibilities to complete a pre-operative visit, return a second time for the procedure itself, await the completion of post-anesthesia care after surgery, and return for a follow-up visit resulting in both additional costs and greater burden of care for families.

Our nurse practitioner team, with the support of our urology surgical physician colleagues, sought to develop a novel, holistic, family-centered ambulatory care model to mitigate these challenges. In collaboration with families and communities to understand their healthcare needs through Boston Children’s Hospital’s Family Advisory Committees and other community partnerships, we heard the challenges parents faced when they could not obtain a circumcision prior to their newborn’s initial hospital discharge. Parents also expressed additional concerns their child would now require an operating room procedure with additional risks of general anesthesia for a procedure which, had there been different circumstances, would have been done under a local anesthetic in a procedural setting closer to the time of their child’s birth.

Program Description

The Transforming Post-Hospitalization, Newborn Circumcision Care Through aNurse Practitioner-Led Care Delivery Model (NCC) was developed to transform traditional practices and to introduce nurse-led, holistic, child and family-focused interventions to provide circumcisions.

The model integrates holistic family and child-centered care delivery practices with attention to intended procedural outcomes. This approach prioritizes newborn comfort, procedurally sound care, and family support through attention to each child’s well-being, parental anxiety, and intentional design to reduce the potential latent risks of early childhood anesthesia, societal and family costs, and the family caregiving time burden and disruption associated with traditional circumcision practices.

In addition, the NCC team developed the Atlas of Healing after NewbornCircumcision (2019) to support families with home care after newborn circumcision. This Atlas is a teaching tool that chronicles normal circumcision healing and is available for use by healthcare providers. The use of this tool was shown to decrease post-operative parent anxiety and facilitate early identification of follow-up care needs after a surgical circumcision. An ongoing program of research and quality improvement has been established to continue to understand and further strengthen clinical outcomes.

Evidence of Success

The NCC has a high level of family satisfaction, few adverse outcomes, and provides both quality and cost benefits in contrast to circumcision procedures completed within an operative setting with general anesthesia. The NCC was created in 2016, with close to 800 circumcisions performed to date over the most recent five years. No documented events were noted in 95.6% of the study cohort at the follow up visit, with penile adhesions noted as the most common concern.

Cost savings of 92.9% were achieved for circumcisions completed in the NCC compared to those completed under general anesthesia by physician providers in traditional operating room settings. Furthermore, key family caregiver benefits including reductions in time away from work for parents related to a less burdensome pre-procedural screening process and reductions in insurance co-pays were also realized.

Resources and References

An Act promoting a resilient health care system that puts patients first, MA BillS.2984, 191st.
Buxton, K., Morgan, A. & Rogers, J. (2017). Nurse Practitioner Lead Pediatric Baclofen Pump Program: Impact on Safety and Quality of Care. Journal of Neuroscience Nursing, 49(5), pp.324–329.
Feeley, D. (2017). The Triple Aim or the Quadruple Aim? Four Points to Help Set Your Strategy. [online] Ihi.org. Available at: http://www.ihi.org/communities/blogs/the-triple-aim-or-the-quadruple-aim-four-points-to-help-set-your-strategy.
Flinter, M. & Bamrick, K. (2017). Training the Next Generation: Residency and Fellowship Programs for Nurse Practitioners in Community Health Centers.[online] www.weitzmaninstitute.org. Available at: https://www.weitzmaninstitute.org/NPResidencyBook [Accessed 19 Sep. 2021].
Harrison, W., & Goodman, D. (2015). Epidemiologic Trends in Neonatal Intensive Care, 2007-2012. JAMA pediatrics, 169 (9), 855–862. https://doi.org/10.1001/jamapediatrics.2015.1305
Houck, C.S. & Vinson, A.E. (2017). Anesthetic considerations for surgery in newborns. Archives of Disease in Childhood - Fetal and Neonatal Edition, 102(4),pp.F359–F363. Institute of Medicine (2011).
The Future of Nursing: Leading Change, Advancing Health. [online] Washington, D.C.: National Academies Press. Available at: https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health.
Joint Commission for Transforming Health Care (2020). High Reliability in Health Care. [online] Centerfortransforminghealthcare.org. Available at: https://www.centerfortransforminghealthcare.org/high-reliability-in-health-care/.
National Academy of Sciences, Engineering, and Medicine (2021). The Future of Nursing 2020-2030. Washington, D.C.: National Academies Press.
Nelson, C.P., Rosoklija, I., Grant, R. & Retik, A.B. (2012). Development and implementation of a photographic atlas for parental instruction and guidance after outpatient penile surgery. Journal of Pediatric Urology, 8(5), pp.521–526.
Owings, M., Uddin, S. & Williams, S. (2013). Trends in Circumcision for MaleNewborns in U.S. Hospitals: 1979-2010. [online] Available at: https://www.cdc.gov/nchs/data/hestat/circumcision_2013/circumcision_2013.pdf.
Sikka, R., Morath, J.M. & Leape, L. (2015). The Quadruple Aim: care, health, cost and meaning in work.
BMJ Quality & Safety, [online] 24(10), pp.608–610.Available at: https://qualitysafety.bmj.com/content/qhc/24/10/608.full.pdf.
Task Force on Circumcision (2012). Circumcision Policy Statement. PEDIATRICS,[online] 130(3), pp.585–586. Available at: https://pediatrics.aappublications.org/content/130/3/585.
US Food and Drug Administration (2019). FDA Drug Safety Communication: FDA approves label changes for use of general anesthetic and sedation drugs in young children. FDA. [online] Available at:
https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-approves-label-changes-use-general-anesthetic-and-sedation-drugs.
Williams, V., Lajoie, D., Nelson, C., Schenkel, S.R., Logvinenko, T., Tecci, K., Porter, C. & Estrada, C. (2020). Experience with implementation of a nurse practitioner led newborn circumcision clinic. Journal of Pediatric Urology, [online] 16(5), pp.651.e1–651.e7. Available at: https://www.sciencedirect.com/science/article/pii/S1477513120304976?via%3Dihub [Accessed 13 Jul. 2021].
Williams, V., Nelson, C. & Estrada, C. (2019). A Photographic Guide to Healing After Newborn Circumcision. Boston Children’s Hospital.
Williams, V., Wood, L. and Lajoie, D. (in review). Leading a Nurse Practitioner designed Newborn Circumcision Clinic. In: C. Betz, ed., Worldwide Successful Pediatric Nurse-Led Models of Care.

Background and Goal

As there is no cure for dementia, patients and families often feel alone in a long and arduous journey without guidance or support. The multiple demands placed on primary care providers often limit their availability to discuss important concerns including advance care planning, legal and financial issues, and advice to family caregivers. To help patients and families navigate the many challenges associated with dementia, Leslie Chang Evertson, GNP-BC, Mihae Kim, AGPCNP-BC, Michelle Panlilio, GNP-BC, and Kelsey Stander, AGNP-BC designed and developed the UCLA Alzheimer’s and Dementia Care (ADC) Program - a collaborative practice in which patients retain their primary care provider while both patients and their families receive dementia care from nurse practitioner Dementia Care Managers (DCMs). The goals of the ADC program are to maximize patient function, independence, and dignity while minimizing caregiver strain and unnecessary costs.

Program Description

Nurses understand that patients are more than their diagnosis alone; they are the sum of their health, social factors, and relationships. Proceeding from this premise, nurse practitioner Dementia Care Managers (DCMs) identify the specific, though diverse, needs of the patients with dementia and their family caregivers. The DCM performs a standardized assessment with each initial and annual visit which includes a dementia focused history and physical, cognitive testing, depression screening for both the patient and caregiver, functional status assessment, and a review of behavioral symptoms. Three acuity levels (red, yellow, and green) have been developed to determine the intensity of care management needed. The DCM communicates with the patient’s team of health providers including his or her primary care provider, physician specialists, hospitals, facilities, and community-based organizations regarding the patient’s dementia assessment and the DCM develops a personalized care plan for each patient and family which is updated as needed over time. In addition to the standardized assessment, the DCM works with the patient and family annually to address issues of advance care planning, legal, and financial concerns. The professional collaboration is mutual, with the patient’s physicians following up with the DCM regarding a concern or to help the patient and family through a crisis. Patients and family members enrolled in the program have 24/7 access to healthcare professionals. Each DCM carries a panel of 250 patients and the program has served over 2600 patients since it began in 2012.

Evidence of Success

The ADC intake visit was perceived to be time well spent by 90% of caregivers surveyed. Similarly, 94% felt that the DCM listened to their concerns and 87% felt that the decisions made during the visit were important to the patient. Almost all (96%) caregivers said they felt supported in their role and 95% of the caregivers would recommend the program to other caregivers. Of the physicians surveyed, 51% believed DCMs provided valuable medical recommendations, 82% believed the ADC provided valuable behavioral and social recommendations, and 87% would recommend the program to other patients. Participants in the UCLA ADC program have reduced caregiver burden, caregiver strain, and caregiver depression after one year. In addition, the program results in reduced nursing home placement and lower healthcare costs – namely a 40% reduction in long-term nursing home placement and a $601 per quarter spending reduction. The UCLA ADC has emerged as a national model for dementia care and was featured in the 2017 National Research Summit on Dementia Care.

Nancy E. Dayhoff, EdD, RN, CNS, Co-Founder, Managing Partner & CEO
Patricia S. Moore, MSN, RN, CNS, CDE, Co-Founder, Managing Partner & COO

Background and Goal

Chronic diseases account for more than 70% of health care costs, and many are associated with modifiable lifestyle decisions. Research demonstrates that an on-going positive relationship with a health-care provider who can individualize teaching and coaching is among the primary drivers of improved self-care decisions and lifestyle behaviors. This is of particular interest to employers, who often cover a large share of those costs and employees who have increasing co-payments or high deductible health plans.

The primary goals of Wise Health Decisions® are to promote self-care decisions and lifestyle behaviors that improve or maintain health, prevent or delay the occurrence of chronic conditions such as hypertension, diabetes, hypercholesterolemia, and obesity, and enhance control of chronic conditions and prevents or delay complications, in concert with medical management.

Program Description

Wise Health Decisions® (WHD) is an innovative self-care management wellness program conducted by RNs built aroundWise Health Decisions® Worksite Wellness Clinics. These RN’s identify employees with or at risk for chronic conditions such as diabetes, hyperlipidemia, hypertension and obesity, and give feedback about outcomes of changes they have made. Individualized teaching/coaching services are based on screening results conducted at each appointment. Monthly bilingual health newsletters on a single topic, are included in payroll envelopes or electronically.

Evidence of Success

• Significant reduction in claims and lower health premium increases have occurred during years when there were no substantial changes in the health plan or employee reduction.
  
• Significant reduction in risk levels across blood pressure, blood sugar, cholesterol and weight measures that are sustained over time.
• Return-on-investment for clients; using cost-avoidance estimates and claims data, is for every $1 spent on WHD, $3-$7 is saved in the initial year.
• 56% - 91% of employees (77% average) voluntarily use the Wellness Clinic, without company incentives; 95%-99% participate with an incentive program.