A nurse practitioner–led care bundle approach for primary care of patients with complex health needs

Abstract

Background: Often developed for acute care and less frequently for primary care, care bundles are clusters of evidence-based practices for improving care delivery and patient outcomes. Care bundles usually arise when ineffective or costly outcomes are identified, are meant to make care more reliable, and require superb teamwork and communication. Local problem: Patients using the highest proportion of health care services are those living with complex health conditions and challenging sociocultural lives, statistics corroborated within our primary care clinic. In our nurse practitioner (NP)-led, interprofessional, team-based primary care program serving mainly low-income patients, we noted that many patients with multiple chronic conditions had an excess of clinic encounters, emergency department visits, and hospitalizations. Methods: To improve health status for these patients and reduce costly care inefficiencies, we developed a unique bundle of care practices for embedding within our NP-led complex care program. Our goals were to improve patient efficacy for self-management of chronic conditions and promote appropriate use of health care resources and services. Interventions: Using AEIØOU as a mnemonic, the derived care bundle better focused our team efforts and provided us with a planning, communication, and documentation schema for quality improvement. It was particularly useful for team-based care because tasks could be documented or communicated by letter or number and easily reviewed by team members or others involved in patients' care. Results: Use of the AEIØOU bundle within our program resulted in better coordination of team-based comprehensive care for our high-needs patients, seen anecdotally in fewer unnecessary contacts and missed appointments and in patient appreciation comments. Emergency department visits and hospitalization data for the six months before compared with 6 months after enrollment in the program showed significant reductions. Conclusions: To improve the primary care of complex patient populations, we recommend further use and testing of the AEIØOU bundle within other care models.

A Systematic Review of Outcomes Related to Nurse Practitioner-Delivered Primary Care for Multiple Chronic Conditions

“…In this review, half of the studies that measured acute care use found a reduction in hospitalizations and ED use for patients who received NP care, while the other half found no significant difference compared with care models without NPs (Christianson-Silva et al, 2021; Fraze et al, 2020; Garfein et al, 2021; Kobb et al, 2003; Sharma et al, 2013; Zulman et al, 2017). However, we noted that the latter studies generally had larger sample sizes and higher methodological quality.…”

“…For instance, in a large, national cohort study of Veteran Health Administration patients with MCCs, those cared for by NPs incurred 6% lower annual expenditures compared with patients cared for by physicians (95% CI = [3, 9], p < .001; Morgan et al, 2019). A small quasi-experimental study of Medicaid patients with MCCs in a single medical center found a 40.6% decrease in total adjusted ED charges, and a 50.3% decrease in adjusted hospital total charges associated with NP care, compared with baseline data (Christianson-Silva et al, 2021). However, one RCT conducted among 583 high-risk veterans found no difference in total health care costs among those who received intensive NP care more than 16 months compared with baseline data (Zulman et al, 2017).…”

“…NPs provided care for MCCs in a variety of health care settings that have different resources for care delivery. For example, studies were conducted in community clinics (Mailliard et al, 2019; Mallow et al, 2018; Sharma et al, 2013), a federally qualified health center (FQHC; Druss et al, 2017), primary care clinics within academic medical centers (Christianson-Silva et al, 2021; Litaker et al, 2003; Talley et al, 2021), and within the Veterans Health Administration (Hummel et al, 2017; Kobb et al, 2003; Zulman et al, 2017). The integration of NP telehealth structures into care for patients in rural areas was represented in two studies, paired with either remote physiologic monitoring or care coordination services (Kobb et al, 2003; Mallow et al, 2018).…”

“…Six studies reported patients’ insurance coverage. Two studies represented patients with Medicare coverage (Chou et al, 2021; Fraze et al, 2020); one represented Medicaid coverage (Christianson-Silva et al, 2021); and three represented a mix of Medicare, Medicaid, and private insurance coverage (Druss et al, 2017; Sharma et al, 2013; Zulman et al, 2017).…”

“…The impact of NP care on ED utilization also produced mixed results. Two quasi-experimental studies reported a reduction in ED visits after NP care compared with baseline data (Christianson-Silva et al, 2021) or usual care (Kobb et al, 2003). In addition, one quasi-experimental study found a slight reduction in combined ED use and hospitalization, compared with a similar patient cohort from the prior year (Sharma et al, 2013).…”