- Email: [email protected]
Practice-education synergy: A research focus on continuity of care
Practice-Education Synergy: A Research Focus on Continuity of Care Jan L. Lee, RIM,PhD,CS Hannah Dean, RN,PhD
This article describes one focus of an ongoing partnership between a Veterans Health Administration medical center and a university-based school of nursing: to improve patient outcomes through patient-centered continuity of care.
N
ursing, because of its social contract to diagnose and treat human responses to health problems, 1 strives to improve the health of the public, especially members of vulnerable populations. Practice-education collaboration is one avenue to maximize nursing effectiveness and patient outcomes. This article describes one goal of an ongoing partnership between a Veterans Health Administration (VHA) medical center and a university-based school of nursing: to improve patient outcomes through patient-centered continuity of care. Patient-centered is stressed since too often continuity of care is defined in terms of the provider (e.g., saw same physician for two appointments in a row) rather than in terms of the patient's need for a coordinated, ongoing plan of care. The context and nature of the collaboration, the mutual goal of improving patient outcomes through continuity of care, and two nursing studies that highlight this synergistic collaboration are also described. The nursing effectiveness and patient outcomes matrix is introduced as a framework to guide variable
NURS OUTLOOK 1995;43:124-8. Copyright © 1995 by Mosby-Year Book, 0029-6554/95/$3.00 + 0
124
Lee and Dean
3511157723
Inc.
i d e n t i f i c a t i o n , including nursingspecific outcomes. The article concludes with an evaluation of the opportunities and challenges one might encounter in developing a research focus in continuity of care. C O N T E X T OF T H E COLLABORATION
The VHA health care system, similar to its civilian counterparts, is undergoing change. In 1991 the Commission on the Future Structure of Veterans Health Care undertook a systematic assessment and analysis of projected patient-care needs and anticipated technological needs. The "mission commission" asserted four fundamental themes in its recommendations: (1) improving access, (2) financing the future, (3) restructuring the system, and (4) enhancing quality of care. 2 Demographic realities underlie the commission's recommendations. Three key demographic trends projected for the next two decades will require the VHA to change (assuming the absence of a major war): ( 1) fewer veterans (from 27 million to 20 million, a 24% decline), (2) more elderly veterans (the number of veterans aged 75 and older will increase 193% during the next two de-
cades, and constitute more than onefifth of all veterans), and (3) more veterans migrating to the Sunbelt states. It is projected that by the year 2010 the states of California, Texas, Florida, New York, and Pennsylvania will be home to a third of all veterans, z On the basis of these demographic influences alone, both VHA hospital discharges and outpatient visits are projected to decline during the next 20 years. However, dramatic changes are expected in health care practice patterns by 2010, including reduced acute hospital use, increased reliance on ambulatory care, and increases in the use of extended care services, whether facility based or community based. 2 The older veteran population means that more attention will need to be paid to the increased prevalence of chronic illnesses and their sequelae. To provide comprehensive care that meets the needs of the increased chronicity in this population, the commission recommends a vertically integrated system with easy patient movement between acute, intermediate, and community- or institutionally based long-term care. An essential element of a high-quality care system is continuity of care, which will enhance the quality of life and maximize functional capacity. 2 In addition, new VHA initiatives are attempting to reflect the broad social shift to increased personal responsibility for health care. Two examples of such initiatives are the Pilot Ambulatory Care and Education (PACE) program, 3 which shifts the focus of health care delivery and health professional education from an inpatient to an outpatient focus, and the VA/ UCLA/RAND Center for the Study of Clinical Decision Making and Provider
VOLUME 43 • NUMBER 3
NURSING OUTLOOK
Behavior, 4which focuses on understanding how health care providers deliver care and why they do what they do. THE NATURE OF THE COLLABORATION The UCLA School of Nursing and the Nursing Service at the Sepulveda VHA Medical Center have enjoyed a longstanding informal relationship. In the fall of 1990, with the advent of the PACE program at the Sepulveda VHA and the development of the chronic care clinical nurse specialist option at UCLA, ~'5a special opportunity for closer collaboration and consultation became apparent. 6 The resulting contractual agreement buys aportion of faculty time to provide expert consultation regarding clinical practice, program development and evaluation, and research. The driving and restraining forces that forged this education-service partnership are described in another article# One product of this education-service partnership is discussed elsewhere. 8 PATIENT-CENTERED CONTINUITY OF CARE The opportunity to improve patient outcomes through patient-centered continuity of care emerged from the philosophy and emphasis of the PACE program, which is organized to provide interdisciplinary care to the veteran population, with a major focus on a generalist outpatient model of care versus the traditional inpatient specialist care model. In the PACE model, the health care professional student moves with the patient among outpatient, inpatient, community, and long-term settings) The opportunities to develop a clinical program of nursing research, in col. laboration with facility personnel, and to establish a faculty practice and primary educational site for the clinical teaching needs of undergraduate and graduate students were particularly appealing. The potential benefits of capitalizing on the interface of educationpractice-research within one clinical site--namely, increased effectiveness, efficiency, and productivity--were obvious. NURSING OUTLOOK
NURSING EFFECTIVENESS A N D PATIENT OUTCOMES MATRIX A framework to guide development of a program of research in patient-centered continuity of care emerged that incorporates the concepts from nursing's metaparadigm: nursing, person, health, and environment, 9 and Holzemer's Model of Patient Outcome Research) ° The nursing effectiveness and patient outcomes matrix provides a comprehensive approach to identifying relevant variables and the relationships among variables (Table 1). It is also useful for specifying the variables to be included in any one particular study (Tables 2 and 3). This framework details nursing's impact on continuity of care and subsequent patient care outcomes. Continuity of care is defined as: "the degree to which the care needed by the patient is coordinated among practitioners and across organizations and time; a component of quality of care. ''n The framework is based in a self-care nursing theory perspective) 2 Thus variables within the model reflect the particular focus of nursing as self-care, the person as a deliberate decision maker and participant in self-care, health and well-being as desired results of nursing and self-care, and the environment as encompassing
MAY/JUNE1995
Nursing Effectiveness and Patient Outcomes Matrix
Patient/Client [Person]*
the socioeconomic-cultural features of the individual and the health system (Table 1). STUDIES USING THE MATRIX Two research studies directly attributable to this education-service collaboration illustrate the usefulness of this matrix in guiding research in continuity of care. Both studies, concerned with continuity of care and the development of selfcare ability, have provided feedback to providers and the health care system, thus contributing directly to continous quality improvement. The first study, "Health Services Utilization and Patterns of Care in a Chronically Ill Veteran Population," had four aims, to: (1) determine the number and describe the characteristics of veterans with a medical diagnosis of diabetes mellitus discharged from the Sepulveda VHA Medical Center during federal fiscal year 1990; (2) examine the influence of sociodemograhic and case mix variables on number of hospital episodes and total number of hospital days; (3) determine the pathway of treatment, or patterns of care, for a subsample of these patients to assess coordination of care and potentially unnecessary or avoidable admissions; and (4) identify
Inputs
Processes
Outcomes
[Person, Nursing,* Environment]
[Person, Nursing,* Environment]
[Health]
Basic conditioning factors ~
Self-care activities*
Health and well-being*
Nursing systems*
Patient/client health and well-being*
Self-care agency*
Provider
Nursing agency~
[NURSING]t Methods of assistance*
Setting [Environment]*
Basic conditioning factors*
Health care system factors t
Models and rules for nursing practice*
*Modified from Holzemerm *Metaparadigm concepts9 *Self-Care Deficit Nursing TheorYconcepts13
Lee and Dean 125
the treatment and organizational variables associated with readmission of patients with diabetes mellitus. This study utilized available databases, including the Patient Treatment File data from the VHA's centralized, inpatient data system, outpatient data available through the facility's Decentralized Hospital Computing System, and chart review data from individual medical records.~3,~4 A follow-up study to investigate the impact of the PACE program on continuity of care and other patient outcomes is in the proposal development stage. The matrix is useful in identifying current variables under study for instance, age, gender, ethnicity under "person/inputs," and number of hospital days under "patient/outcomes." It is equally useful in specifying variables of interest for investigation in future studies. For example, with the advent of the PACE program, some patients have received case management services from a clinical nurse specialist. The variable of clinical nurse specialist case management would be placed under "provider/processes."
The second study, "Telephone Triage Care: Description, Evaluation, and Improvement," was designed to: (1) describe the number and type of calls, nursing intervention, and disposition of telephone triage care delivered in one veteran ambulatory care service, (2) identify target patient problems needing improvement in care provided, (3) develop a prototype approach to clinical guidelines development for a highpriority patient problem, (4) determine patient and provider satisfaction with triage care, and (5) solicit patient and provider suggestions for improvement of telephone careJ 5 Results from this study have contributed to several efforts at quality improvement. For example, the need for an enhanced nursing orientation/staff development program for nurses providing telephone care was identified through the nurse satisfaction interviews conducted for this study. Phase I of this staff development program has now been implemented. Variables of interest in the telephone triage project easily lend themselves to
classification in the matrix framework (Table 3). For instance, the chief complaint is a variable under "patient/inputs," while type of nursing intervention is a variable under "provider/processes." Decreased number of walk-in clinic visits is a "setting/outcomes" variable. OPPORTUNITIES AND CHALLENGES
Styles' nine dyads of competing forces shaping nursing's movement into the 21st century provide a context for analyzing the opportunities and challenges inherent in developing a research program in continuity of care) 6
Quafity : Cost Continuity of care is an important aspect of quality of care. The costs associated with subpar continuity of care encompass costs to the patient (delays in needed treatments, pain and suffering, poor patient satisfaction), the provider (inefficient use of time, duplication of services, decreased job satisfaction), and the setting (unnecessary use of tests, poor utilization of services, inappropriate use of costly services).
Focus : Expand Nursing Effectiveness and Patient Outcomes Matrix Patient/Client
Inputs
Demographics; disease variables; comorbidities
Keeping appointments
Outcomes
Self-care skills; adherance to care plan; glycemic control; complications; No. of hospital days; length of stay; No. admits; mortality
Provider
Type of provider
Education; referral; diagnostic tests, prescriptions
Consistent case load
Setting
Eligibility
Type of clinic; Telephone Triage Care Program
Decreased length of stay; decreased inappropriate admits and readmits
requirements; geographic location
126
Processes
Lee and Dean
The assessment and monitoring of continuity of care is both a focused effort (see studies described above) and a comprehensive effort to expand or increase continuity of care within an organization's health care services. To ensure ongoing success, continuous quality improvement efforts must be integrated both within departments and across departments.
Nursing Values : Marketplace Values Nursing's focus on the patient as central to care bodes well in an increasingly consumer-driven system of care. The present marketplace value of cost containment is too often erroneously perceived as competing with the need for continuous quality improvement. Both quality care issues and business realities must be attended to for economic survival.
VOLUME 43 • NUMBER 3
NURSING OUTLOOK
Shaping : Reacting The matrix framework described here provides a structure within which to study continuity of care retrospectively, concurrently, and prospectively, as the situation warrants. The basic elements of a research program in continuity of care, variables and relationships, as illustrated in the matrix, can be studied through reacting to the situation as it is, or testing the situation as it might be (e.g., adding a nursing case management program of care).
Independence :Integration Research in continuity of care requires both the independence of the investigator to pursue a systematic investigation of the phenomenon and the ability of the investigator (or team) to integrate the findings back into the organization, into care delivery. Integration is a vital aspect of continuous quality improvement.
hanced by looking outward--to share successes and failures in continuity of care and to compare what is happening in the "outside world" with what is happening inside the specific system under study.
Opportunity : Disaster Opportunities abound for improving continuity of care within health care organizations. Improvements in continuity of care benefit patients, providers, and settings. Improved continuity of care also has the potential to improve the bottom line. Disaster awaits those who ignore the patient, provider, and setting outcomes {benefits) of continuity of care. SUMMARY In this article we have described one focus of an ongoing partnership between a VHA medical center and a universitybased school of nursing: to improve patient outcomes through a research pro-
gram focused on patient-centered continuity of care. A nursing effectiveness and patient outcomes matrix was introduced as a framework to guide variable identification, including nursing-specific outcomes. Opportunities and challenges inherent in developing this program of research were discussed. The synergy of a successful practice-education collaboration not only strengthens the links between practice and education but may also directly affect patient-centered outcomes of nursing care. I An earlier version of this paper was presentedat the conference,"Pathwaysto Partnerships:Present and Future,"sponsoredby the AmericanAcademy of Nursing in cooperation with the American Nurses AssociationCouncil on NursingAdministration, AmericanOrganizationof Nurse Executives, and the Councilon GraduateEducationfor Administration in Nursing, October 11-12, 1992, St. Louis,Mo+ Funded by Western Region VHA and UCLA School of Nursing Minigrants, 1990-1991 and 1991-92.
Health Services : Social~Human Services Traditional health care service concerns, such as length of stay and number of readmissions, are important variables in continuity of care research. Equally important are provider and patient satisfaction with care delivered and received. Continuity of care is best accomplished through the efforts of an interdisciplinary team, which includes physicians, nurses, advanced practice nurses, social workers, psychiatric/psychology services, pharmacists, and other health care providers, as appropriate to patient needs.
Nursing Effectiveness and Patient Outcomes Matrix
Processes
Outcomes
Demographics; disease variables
Participation in care plan process; use of services
Self-care skills; adherance to care plan; glycemic control; complications; No. hospital days; No. admits; QOL; mortality
Provider
CNS (as case manager)
Case management program
Satisfaction with care provided, with role; perceived effectivenes
Setting
Capacity; eligibility requirements; geographic location
Interdisciplinary team policies
Decreased length of stay; decreased inappropriate admits and readmits; appropriate use of services (decreased walk-ins)
Patient/Client
Inputs
Acute Care : Wellness Care Acute care and wellness care are essential parts of the continuum of care for any patient. W h i l e acute care and wellness care services are usually separate, they are also connected, since continuity of care is defined in terms of the patient.
Look Inward : Look Outward Looking inward (at a particular unit or facility) helps to identify what is working, and what is not working, to improve continuity of care. But looking inward is not enough. Looking inward must be enNURSING OUTLOOK
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127
REFERENCES 1. American Nurses Association. Nursing: a social policy statement. Kansas City, Missouri: American Nurses Association, I980. 2. Commission on the Future Structure of Veterans Health Care. Report. Washington: Office of the Secretary, Department of Veterans Affairs, 1991. 3. Robbins AS, Linder RL, Fihn SD, Guze PA, McCoy JM, Nardone DA. Status report on ambulatory care and education in the VA western region and western medical schools. Acad Med 1991;66:506-10. 4. Rubenstein L, Mittman B. Announcement of VA/UCLA/RAND Center for the Study of Clinical Decision Making and Provider Behavior. Sepulveda, California: Feb 22, 1993. 5. Chang BL, Lee JL, Faherty B, Hirsch M. Community participation in curriculum development: a three-pronged approach. J Nurs Ed I993;32:376-8. 6. Dean H. Panel discussion on the role of top management in fostering ambulatory care and education. Presented at DVA Western Region, Long Beach RMEC, The ACE Advisory Committee Conference: Ambulatory Care and Education Development Conference. Palo Alto, California: July 26-27, 1990.
7. Dean H, Lee JL. Service and education: forging a partnership. Paper presented at the American Academy of Nursing. St. Louis, Missouri: October 11-I2, 1992. 8. Lee JL, Vivell S, Turner CL, Campbell LJ, Stevens B. Validating a compendium of goals and objectives for educating clinical nurse specialist students. Clin Nurs Spec 1993; 7:206i2. 9. Fawcett J. Analysis and evaluation of conceptual models of nursing. 2nd ed. Philadelphia: FA Davis, 1989. 10. Holzemer W. Nursing effectiveness research and patient outcomes. Paper presented at the 1992 Western Society for Research in Nursing Post-Doctoral Clinical Research Seminar, "The Cost, Quality, Outcome Connection: Implications for Research Design." San Diego: April 29, 1992. 11. Department of Veterans Affairs. An update: clinical indicators for quality improvement. Department of Veterans Affairs Teleconference, Aug 19, 1992. 12. Orem DE. Nursing concepts of practice. 4th ed. St. Louis: Mosby-Year Book, 1991. 13. Lee JL, Jones KR, Johnson Fix], HoenshellNelson N. Health services utilization in a chronically ill veteran population. Poster presented at Sigma Theta Tau International Nuts-
ing Research Conference. Columbus, Ohio: May 19, 1992. 14. Lee JL, Jones KR, Johnson FN, HoenshellNelson N. Patterns of care in a chronically ill veteran population. Paper presented at Department of Veterans Affairs Second National Nursing Research Conference, Las Vegas:June 22, 1992. 15. Lee JL, Gaffney-Lerman M, Turner CL, Schulman B, Dean H, Halverson J. Telephone triage care: a nursing ambulatory care delivery method. In: Dean HE, Willard G, eds. Innovations in ambulatory care nursing: proceedings of the DVA Western Region ACE Nursing Conference. San Francisco: DVA Western Region, 1994. 16. Styles MM. Summary and recommendations. In: Nursing practice in the 21st century. Kansas City, Missouri: American Nurses Foundation, 1988:53-62.
JAN L. LEE is an assistant professor in the Primary Care Section of the UCLA School of Nursing, in Los Angeles. HANNAH DEAN is associate chief of Nursing Service/Research at the VHA Medical Center in Sepulveda, California.
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128
Lee and Dean
V O L U M E 43 • NUMBER 3
NURSING O U T L O O K
This article describes one focus of an ongoing partnership between a Veterans Health Administration medical center and a university-based school of nursing: to improve patient outcomes through patient-centered continuity of care.
N
ursing, because of its social contract to diagnose and treat human responses to health problems, 1 strives to improve the health of the public, especially members of vulnerable populations. Practice-education collaboration is one avenue to maximize nursing effectiveness and patient outcomes. This article describes one goal of an ongoing partnership between a Veterans Health Administration (VHA) medical center and a university-based school of nursing: to improve patient outcomes through patient-centered continuity of care. Patient-centered is stressed since too often continuity of care is defined in terms of the provider (e.g., saw same physician for two appointments in a row) rather than in terms of the patient's need for a coordinated, ongoing plan of care. The context and nature of the collaboration, the mutual goal of improving patient outcomes through continuity of care, and two nursing studies that highlight this synergistic collaboration are also described. The nursing effectiveness and patient outcomes matrix is introduced as a framework to guide variable
NURS OUTLOOK 1995;43:124-8. Copyright © 1995 by Mosby-Year Book, 0029-6554/95/$3.00 + 0
124
Lee and Dean
3511157723
Inc.
i d e n t i f i c a t i o n , including nursingspecific outcomes. The article concludes with an evaluation of the opportunities and challenges one might encounter in developing a research focus in continuity of care. C O N T E X T OF T H E COLLABORATION
The VHA health care system, similar to its civilian counterparts, is undergoing change. In 1991 the Commission on the Future Structure of Veterans Health Care undertook a systematic assessment and analysis of projected patient-care needs and anticipated technological needs. The "mission commission" asserted four fundamental themes in its recommendations: (1) improving access, (2) financing the future, (3) restructuring the system, and (4) enhancing quality of care. 2 Demographic realities underlie the commission's recommendations. Three key demographic trends projected for the next two decades will require the VHA to change (assuming the absence of a major war): ( 1) fewer veterans (from 27 million to 20 million, a 24% decline), (2) more elderly veterans (the number of veterans aged 75 and older will increase 193% during the next two de-
cades, and constitute more than onefifth of all veterans), and (3) more veterans migrating to the Sunbelt states. It is projected that by the year 2010 the states of California, Texas, Florida, New York, and Pennsylvania will be home to a third of all veterans, z On the basis of these demographic influences alone, both VHA hospital discharges and outpatient visits are projected to decline during the next 20 years. However, dramatic changes are expected in health care practice patterns by 2010, including reduced acute hospital use, increased reliance on ambulatory care, and increases in the use of extended care services, whether facility based or community based. 2 The older veteran population means that more attention will need to be paid to the increased prevalence of chronic illnesses and their sequelae. To provide comprehensive care that meets the needs of the increased chronicity in this population, the commission recommends a vertically integrated system with easy patient movement between acute, intermediate, and community- or institutionally based long-term care. An essential element of a high-quality care system is continuity of care, which will enhance the quality of life and maximize functional capacity. 2 In addition, new VHA initiatives are attempting to reflect the broad social shift to increased personal responsibility for health care. Two examples of such initiatives are the Pilot Ambulatory Care and Education (PACE) program, 3 which shifts the focus of health care delivery and health professional education from an inpatient to an outpatient focus, and the VA/ UCLA/RAND Center for the Study of Clinical Decision Making and Provider
VOLUME 43 • NUMBER 3
NURSING OUTLOOK
Behavior, 4which focuses on understanding how health care providers deliver care and why they do what they do. THE NATURE OF THE COLLABORATION The UCLA School of Nursing and the Nursing Service at the Sepulveda VHA Medical Center have enjoyed a longstanding informal relationship. In the fall of 1990, with the advent of the PACE program at the Sepulveda VHA and the development of the chronic care clinical nurse specialist option at UCLA, ~'5a special opportunity for closer collaboration and consultation became apparent. 6 The resulting contractual agreement buys aportion of faculty time to provide expert consultation regarding clinical practice, program development and evaluation, and research. The driving and restraining forces that forged this education-service partnership are described in another article# One product of this education-service partnership is discussed elsewhere. 8 PATIENT-CENTERED CONTINUITY OF CARE The opportunity to improve patient outcomes through patient-centered continuity of care emerged from the philosophy and emphasis of the PACE program, which is organized to provide interdisciplinary care to the veteran population, with a major focus on a generalist outpatient model of care versus the traditional inpatient specialist care model. In the PACE model, the health care professional student moves with the patient among outpatient, inpatient, community, and long-term settings) The opportunities to develop a clinical program of nursing research, in col. laboration with facility personnel, and to establish a faculty practice and primary educational site for the clinical teaching needs of undergraduate and graduate students were particularly appealing. The potential benefits of capitalizing on the interface of educationpractice-research within one clinical site--namely, increased effectiveness, efficiency, and productivity--were obvious. NURSING OUTLOOK
NURSING EFFECTIVENESS A N D PATIENT OUTCOMES MATRIX A framework to guide development of a program of research in patient-centered continuity of care emerged that incorporates the concepts from nursing's metaparadigm: nursing, person, health, and environment, 9 and Holzemer's Model of Patient Outcome Research) ° The nursing effectiveness and patient outcomes matrix provides a comprehensive approach to identifying relevant variables and the relationships among variables (Table 1). It is also useful for specifying the variables to be included in any one particular study (Tables 2 and 3). This framework details nursing's impact on continuity of care and subsequent patient care outcomes. Continuity of care is defined as: "the degree to which the care needed by the patient is coordinated among practitioners and across organizations and time; a component of quality of care. ''n The framework is based in a self-care nursing theory perspective) 2 Thus variables within the model reflect the particular focus of nursing as self-care, the person as a deliberate decision maker and participant in self-care, health and well-being as desired results of nursing and self-care, and the environment as encompassing
MAY/JUNE1995
Nursing Effectiveness and Patient Outcomes Matrix
Patient/Client [Person]*
the socioeconomic-cultural features of the individual and the health system (Table 1). STUDIES USING THE MATRIX Two research studies directly attributable to this education-service collaboration illustrate the usefulness of this matrix in guiding research in continuity of care. Both studies, concerned with continuity of care and the development of selfcare ability, have provided feedback to providers and the health care system, thus contributing directly to continous quality improvement. The first study, "Health Services Utilization and Patterns of Care in a Chronically Ill Veteran Population," had four aims, to: (1) determine the number and describe the characteristics of veterans with a medical diagnosis of diabetes mellitus discharged from the Sepulveda VHA Medical Center during federal fiscal year 1990; (2) examine the influence of sociodemograhic and case mix variables on number of hospital episodes and total number of hospital days; (3) determine the pathway of treatment, or patterns of care, for a subsample of these patients to assess coordination of care and potentially unnecessary or avoidable admissions; and (4) identify
Inputs
Processes
Outcomes
[Person, Nursing,* Environment]
[Person, Nursing,* Environment]
[Health]
Basic conditioning factors ~
Self-care activities*
Health and well-being*
Nursing systems*
Patient/client health and well-being*
Self-care agency*
Provider
Nursing agency~
[NURSING]t Methods of assistance*
Setting [Environment]*
Basic conditioning factors*
Health care system factors t
Models and rules for nursing practice*
*Modified from Holzemerm *Metaparadigm concepts9 *Self-Care Deficit Nursing TheorYconcepts13
Lee and Dean 125
the treatment and organizational variables associated with readmission of patients with diabetes mellitus. This study utilized available databases, including the Patient Treatment File data from the VHA's centralized, inpatient data system, outpatient data available through the facility's Decentralized Hospital Computing System, and chart review data from individual medical records.~3,~4 A follow-up study to investigate the impact of the PACE program on continuity of care and other patient outcomes is in the proposal development stage. The matrix is useful in identifying current variables under study for instance, age, gender, ethnicity under "person/inputs," and number of hospital days under "patient/outcomes." It is equally useful in specifying variables of interest for investigation in future studies. For example, with the advent of the PACE program, some patients have received case management services from a clinical nurse specialist. The variable of clinical nurse specialist case management would be placed under "provider/processes."
The second study, "Telephone Triage Care: Description, Evaluation, and Improvement," was designed to: (1) describe the number and type of calls, nursing intervention, and disposition of telephone triage care delivered in one veteran ambulatory care service, (2) identify target patient problems needing improvement in care provided, (3) develop a prototype approach to clinical guidelines development for a highpriority patient problem, (4) determine patient and provider satisfaction with triage care, and (5) solicit patient and provider suggestions for improvement of telephone careJ 5 Results from this study have contributed to several efforts at quality improvement. For example, the need for an enhanced nursing orientation/staff development program for nurses providing telephone care was identified through the nurse satisfaction interviews conducted for this study. Phase I of this staff development program has now been implemented. Variables of interest in the telephone triage project easily lend themselves to
classification in the matrix framework (Table 3). For instance, the chief complaint is a variable under "patient/inputs," while type of nursing intervention is a variable under "provider/processes." Decreased number of walk-in clinic visits is a "setting/outcomes" variable. OPPORTUNITIES AND CHALLENGES
Styles' nine dyads of competing forces shaping nursing's movement into the 21st century provide a context for analyzing the opportunities and challenges inherent in developing a research program in continuity of care) 6
Quafity : Cost Continuity of care is an important aspect of quality of care. The costs associated with subpar continuity of care encompass costs to the patient (delays in needed treatments, pain and suffering, poor patient satisfaction), the provider (inefficient use of time, duplication of services, decreased job satisfaction), and the setting (unnecessary use of tests, poor utilization of services, inappropriate use of costly services).
Focus : Expand Nursing Effectiveness and Patient Outcomes Matrix Patient/Client
Inputs
Demographics; disease variables; comorbidities
Keeping appointments
Outcomes
Self-care skills; adherance to care plan; glycemic control; complications; No. of hospital days; length of stay; No. admits; mortality
Provider
Type of provider
Education; referral; diagnostic tests, prescriptions
Consistent case load
Setting
Eligibility
Type of clinic; Telephone Triage Care Program
Decreased length of stay; decreased inappropriate admits and readmits
requirements; geographic location
126
Processes
Lee and Dean
The assessment and monitoring of continuity of care is both a focused effort (see studies described above) and a comprehensive effort to expand or increase continuity of care within an organization's health care services. To ensure ongoing success, continuous quality improvement efforts must be integrated both within departments and across departments.
Nursing Values : Marketplace Values Nursing's focus on the patient as central to care bodes well in an increasingly consumer-driven system of care. The present marketplace value of cost containment is too often erroneously perceived as competing with the need for continuous quality improvement. Both quality care issues and business realities must be attended to for economic survival.
VOLUME 43 • NUMBER 3
NURSING OUTLOOK
Shaping : Reacting The matrix framework described here provides a structure within which to study continuity of care retrospectively, concurrently, and prospectively, as the situation warrants. The basic elements of a research program in continuity of care, variables and relationships, as illustrated in the matrix, can be studied through reacting to the situation as it is, or testing the situation as it might be (e.g., adding a nursing case management program of care).
Independence :Integration Research in continuity of care requires both the independence of the investigator to pursue a systematic investigation of the phenomenon and the ability of the investigator (or team) to integrate the findings back into the organization, into care delivery. Integration is a vital aspect of continuous quality improvement.
hanced by looking outward--to share successes and failures in continuity of care and to compare what is happening in the "outside world" with what is happening inside the specific system under study.
Opportunity : Disaster Opportunities abound for improving continuity of care within health care organizations. Improvements in continuity of care benefit patients, providers, and settings. Improved continuity of care also has the potential to improve the bottom line. Disaster awaits those who ignore the patient, provider, and setting outcomes {benefits) of continuity of care. SUMMARY In this article we have described one focus of an ongoing partnership between a VHA medical center and a universitybased school of nursing: to improve patient outcomes through a research pro-
gram focused on patient-centered continuity of care. A nursing effectiveness and patient outcomes matrix was introduced as a framework to guide variable identification, including nursing-specific outcomes. Opportunities and challenges inherent in developing this program of research were discussed. The synergy of a successful practice-education collaboration not only strengthens the links between practice and education but may also directly affect patient-centered outcomes of nursing care. I An earlier version of this paper was presentedat the conference,"Pathwaysto Partnerships:Present and Future,"sponsoredby the AmericanAcademy of Nursing in cooperation with the American Nurses AssociationCouncil on NursingAdministration, AmericanOrganizationof Nurse Executives, and the Councilon GraduateEducationfor Administration in Nursing, October 11-12, 1992, St. Louis,Mo+ Funded by Western Region VHA and UCLA School of Nursing Minigrants, 1990-1991 and 1991-92.
Health Services : Social~Human Services Traditional health care service concerns, such as length of stay and number of readmissions, are important variables in continuity of care research. Equally important are provider and patient satisfaction with care delivered and received. Continuity of care is best accomplished through the efforts of an interdisciplinary team, which includes physicians, nurses, advanced practice nurses, social workers, psychiatric/psychology services, pharmacists, and other health care providers, as appropriate to patient needs.
Nursing Effectiveness and Patient Outcomes Matrix
Processes
Outcomes
Demographics; disease variables
Participation in care plan process; use of services
Self-care skills; adherance to care plan; glycemic control; complications; No. hospital days; No. admits; QOL; mortality
Provider
CNS (as case manager)
Case management program
Satisfaction with care provided, with role; perceived effectivenes
Setting
Capacity; eligibility requirements; geographic location
Interdisciplinary team policies
Decreased length of stay; decreased inappropriate admits and readmits; appropriate use of services (decreased walk-ins)
Patient/Client
Inputs
Acute Care : Wellness Care Acute care and wellness care are essential parts of the continuum of care for any patient. W h i l e acute care and wellness care services are usually separate, they are also connected, since continuity of care is defined in terms of the patient.
Look Inward : Look Outward Looking inward (at a particular unit or facility) helps to identify what is working, and what is not working, to improve continuity of care. But looking inward is not enough. Looking inward must be enNURSING OUTLOOK
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REFERENCES 1. American Nurses Association. Nursing: a social policy statement. Kansas City, Missouri: American Nurses Association, I980. 2. Commission on the Future Structure of Veterans Health Care. Report. Washington: Office of the Secretary, Department of Veterans Affairs, 1991. 3. Robbins AS, Linder RL, Fihn SD, Guze PA, McCoy JM, Nardone DA. Status report on ambulatory care and education in the VA western region and western medical schools. Acad Med 1991;66:506-10. 4. Rubenstein L, Mittman B. Announcement of VA/UCLA/RAND Center for the Study of Clinical Decision Making and Provider Behavior. Sepulveda, California: Feb 22, 1993. 5. Chang BL, Lee JL, Faherty B, Hirsch M. Community participation in curriculum development: a three-pronged approach. J Nurs Ed I993;32:376-8. 6. Dean H. Panel discussion on the role of top management in fostering ambulatory care and education. Presented at DVA Western Region, Long Beach RMEC, The ACE Advisory Committee Conference: Ambulatory Care and Education Development Conference. Palo Alto, California: July 26-27, 1990.
7. Dean H, Lee JL. Service and education: forging a partnership. Paper presented at the American Academy of Nursing. St. Louis, Missouri: October 11-I2, 1992. 8. Lee JL, Vivell S, Turner CL, Campbell LJ, Stevens B. Validating a compendium of goals and objectives for educating clinical nurse specialist students. Clin Nurs Spec 1993; 7:206i2. 9. Fawcett J. Analysis and evaluation of conceptual models of nursing. 2nd ed. Philadelphia: FA Davis, 1989. 10. Holzemer W. Nursing effectiveness research and patient outcomes. Paper presented at the 1992 Western Society for Research in Nursing Post-Doctoral Clinical Research Seminar, "The Cost, Quality, Outcome Connection: Implications for Research Design." San Diego: April 29, 1992. 11. Department of Veterans Affairs. An update: clinical indicators for quality improvement. Department of Veterans Affairs Teleconference, Aug 19, 1992. 12. Orem DE. Nursing concepts of practice. 4th ed. St. Louis: Mosby-Year Book, 1991. 13. Lee JL, Jones KR, Johnson Fix], HoenshellNelson N. Health services utilization in a chronically ill veteran population. Poster presented at Sigma Theta Tau International Nuts-
ing Research Conference. Columbus, Ohio: May 19, 1992. 14. Lee JL, Jones KR, Johnson FN, HoenshellNelson N. Patterns of care in a chronically ill veteran population. Paper presented at Department of Veterans Affairs Second National Nursing Research Conference, Las Vegas:June 22, 1992. 15. Lee JL, Gaffney-Lerman M, Turner CL, Schulman B, Dean H, Halverson J. Telephone triage care: a nursing ambulatory care delivery method. In: Dean HE, Willard G, eds. Innovations in ambulatory care nursing: proceedings of the DVA Western Region ACE Nursing Conference. San Francisco: DVA Western Region, 1994. 16. Styles MM. Summary and recommendations. In: Nursing practice in the 21st century. Kansas City, Missouri: American Nurses Foundation, 1988:53-62.
JAN L. LEE is an assistant professor in the Primary Care Section of the UCLA School of Nursing, in Los Angeles. HANNAH DEAN is associate chief of Nursing Service/Research at the VHA Medical Center in Sepulveda, California.
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