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 | Principal Investigator:Ryan J. Shaw, Ph.D., R.N. Evidence-based Synthesis Program (ESP) Center, Durham Veterans Affairs Healthcare System, Durham, NC Washington (DC): Department of Veterans Affairs; August 2013 |
Download PDF: Complete Report, Executive Summary, Report, Appendices
Background
Medical management of chronic illness consumes 75 percent of every health care dollar spentin the United States, and the provision of economical, accessible, and high-quality chronicdisease care is a continuing concern across health care settings. Type 2 diabetes, hypertension,hyperlipidemia, and congestive heart failure are prime examples of common chronic diseasesthat cause substantial morbidity and mortality and require long-term medical management andsupport.
For each of these disease conditions, the majority of care occurs in outpatient settings wherewell-established clinical practice guidelines can be used to guide treatment decisions. Despitethe availability of these guidelines, practice recommendations often are not implementedwhich contributes to suboptimal clinical outcomes. The shortage of primary care clinicians inoutpatient care settings has been identified as a barrier to the provision of comprehensive chronicdisease care and provides an impetus to develop and test strategies for expanding the roles andresponsibilities of other members of the interdisciplinary team to help meet the continuallyincreasing need for chronic disease care.
In an effort to serve more Veterans and improve the quality and efficiency of chronic diseasecare, the Department of Veterans Affairs (VA) is implementing Patient Aligned Care Teams(PACTs)—a model of primary care transformation that builds on other widely disseminatedefforts such as the chronic care model. VA PACTs are adaptations of the patient-centered medicalhome, which includes the following core principles: wide-ranging, team-based care; patientcenteredorientation toward the whole person; care that is coordinated across all elements of thehealth care system and the patient's community; enhanced access to care that uses alternativemethods of communication; and a systems-based approach to quality and safety. VA PACTclinical teams may include nurses (registered nurses [RNs] or licensed practical nurses [LPNs])as well as primary care providers, clinical pharmacists, behavioral health specialists, and clinicfacilitators. An organizing principle for these care teams is to utilize personnel at the highestlevel of their skill set. The Institute of Medicine has recommended the expansion of nurses' rolesand responsibilities to allow them to practice to the full extent of their education and training.
Reports of the contributions of nurses in improving access and quality of care for patients withselected chronic conditions by using detailed structured protocols developed by or throughconsultation with physicians began in the late 1960s. There is now robust evidence supportingthe effectiveness of nurses in providing patient education about chronic disease treatment, selfcaremanagement, and secondary prevention strategies as well as the ability of nurse practitioners(NPs) to provide effective and cost-effective primary care. As the largest segment of the healthcare workforce, nurses are ideally suited to collaborate with other professionals in meetingthe increasing demand for chronic care. Nurses are experienced and accustomed to working inmultidisciplinary teams and, with clearly defined clinical protocols and additional training, safelypractice beyond their usual scope of practice and may well be able to order relevant diagnostictests, adjust routine medication regimens, and appropriately refer complicated or unstablepatients for further medical evaluation.
The VA is in the process of developing protocols and policies expanding the nurse's role asa member of PACT teams. A protocol contains a series of actions in accordance with currentclinical guidelines or standards of practice that are implemented by nurses to manage a patient'scondition. At the VA, there is emerging interest in allowing nurses to practice in an expanded rolethat includes medication initiation or titration under guidelines of protocols. The lack of certaintyregarding outcomes associated with the use of clinical protocols by non-NP nurses in expandedroles led the VA to commission this evidence synthesis. We thus synthesized the current literatureto describe the effects of nurse-managed protocols for the outpatient management of adultswith high-impact, chronic conditions such as type 2 diabetes, hypertension, hyperlipidemia, andcongestive heart failure (CHF).
We addressed the following key questions:
- Nursing staff experience (e.g., satisfaction)
- Treatment adherence
- Quality measures such as
- Biophysical markers (e.g., laboratory or physiological markers of health statussuch as HbA1c and blood pressure)
- Process-of-care measures used by VA, National Quality Forum, or NationalCommittee for Quality Assurance
- Resource utilization
See also
- A Systematic Review: Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Conditions (Management eBrief)
- Shaw R, McDuffie J, Hendrix C, Edie A, Lindsey-Davis L, Nagi A, Kosinski A, Williams JW. Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Conditions: A Systematic Review and Meta-Analysis. Ann Intern Med. 2014;161(2):113-121.
- Spotlight on Evidence-based Synthesis Program: Effects of Nurse-Managed Protocols in the Outpatient Management of Adults with Chronic Conditions (Cyberseminar)
