Tracking psych nursing outcomes pays off
Caseload increased 1100% in just one year
When the Visiting Nurse Service of Greater Woonsocket decided to enter the psychiatric nursing field, its first step was to set up an outcomes tracking and documenting system.
Then, the Lincoln, RI-based agency was able to use the data gathered in field testing of its Outcomes Planner to generate referrals from local mental health centers and to secure contracts from third-party payers, including a major health maintenance organization (HMO).
"By showing what outcomes we measured and what they were, we were able to go statewide and pick up every mental health center in Rhode Island. They didn’t want to trust their patients to people who couldn’t provide documentation of what they could accomplish," says Jo-Ann Daniel-Lemoine, PhD, RNC, director of the Outcomes Planner project and quality improvement.
The VNS decided to enter the psychiatric nursing field in January, 1995, and hired psychiatric nurse-manager Jon Korzeniowski, RN, BA, to set up the outcomes system.
Korzeniowski brought in three masters’-level psychiatric nurse clinicians from other agencies to help develop the outcomes measuring tool for psychiatric nursing. In return for the loaned expertise, the agencies were allowed to use VNS' Outcomes Planner for free.
The team began by compiling a list of 18 different psychiatric nursing disorders likely to be treated in the home care setting. Using the copyrighted format of VNS' other Outcomes Planner tools, they outlined treatment for each disorder and created critical pathways.
Next, they discussed how to measure outcomes for each disorder and assembled tools to measure each of the outcomes they wanted to track. They chose tools that are already validated for measuring psychiatric outcomes, such as anxiety and depression scales. (See anxiety scale, p. 35.)
After working for six months to develop the product, the nurses took the planner back to their respective agencies and field-tested it from July to December, 1996.
Korzeniowski used the data gathered from the field testing to generate the first joint ventures with mental health centers to handle patients who either were hospitalized because home treatment was not available, or who were at home but receiving periodic visits from the mental health center.
VNS began its psychiatric nursing program with one nurse in July, 1995, and grew to a staff of 30 nurses making 12,544 patient visits per year by the end of 1996. The number of patients increased by 1100% over the same period, Daniel-Lemoine says.
Give payers statistical info
"The Outcomes Planner gives us the ability to develop a quality treatment program based on quality outcomes. We’re not just going out and saying we are going to manage the patient as best we can. We give the payers and other referral sources exact statistical information," Daniel-Lemoine says.
Nurses at VNS administer the mental status tools on the first visit and usually at nine-visit intervals. (For a look at the documentation they use for the first visit, see the chart on p. 34.) They administer the OASIS functional outcomes measures on the second visit.
Administering the two tools and recording data adds 10 to 20 minutes per visit, Daniel-Lemoine says.
The agency uses data from the outcomes measuring system for quality improvement projects.
A performance improvement committee, led by Daniel-Lemoine, analyzes outcomes for the entire VNS staff and gives each department an area that is its primary focus. Each department must come up with a CQI project to improve the outcome.
For instance, when statistics showed that depression clients weren’t meeting the agency’s goal of being able to manage their medications by the second visit, the psychiatric nursing department created a project to help patients learn their medication routine.
The agency conducted inservice training for the entire psychiatric nursing staff to make sure all the nurses were using the same medication teaching techniques. The second step was to design and implement a teaching tool for medication.
Scores increased after the inservice training, Daniel-Lemoine says. Data are not yet available on the effectiveness of the teaching tool, she adds.
Among the data the VNS is able to provide to referral sources are a list of outcomes tracked for each disease state, the percentage of patients meeting each outcome, and average visits per month per disease state.
VNS’ Outcomes Planner is a critical pathway that outlines all the short-term and long-term goals for each disease state. For instance, there are three long-term goals and 32 short-term goals for the anxiety client. (For examples of some of the goals, see chart on p. 35.)
Following each intervention, whether it is a counseling or instructional session, the nurse answers "yes" or "no" to all of the items scheduled for that session, and from there measures the outcomes.
Items on the check-off list might include:
• Client demonstrates keeping or scheduling appointments.
• Client demonstrates participation in activities of daily living.
• Client demonstrates appropriate coping skills.
• Client can verbalize early warning signs of anxiety.
The nurses also periodically measure patient status using psychiatric scales appropriate to each disease state.
The Outcomes Planner also addresses issues that can affect the patient’s medical conditions if the patient’s psychiatric disease is not under control. Medication administration, appropriate rest, and activity patterns are among the items tracked.
For instance, the VNS can tell a payer that X percent of depression clients can manage medication by visit 2, or that X percent of schizophrenic patients are able to manage activities of daily living by visit 3.
Payers are especially interested in this segment of the Outcomes Planner because they want to ensure that the clients’ medical conditions as well as their psychiatric conditions are managed to avoid readmission to the hospital, Daniel-Lemoine says.
VNS also has found the Outcomes Planner useful as an orientation tool for psychiatric nurses who are entering the home care field for the first time because it is a critical pathway that outlines all of the steps in meeting the short-term and long-term goals.
VNS also has compiled statistics on triage calls to the mental health center at night, and on patients readmitted to the mental health center. For instance, in the first year, VNS provided 1,455 visits to mental health patient clients. During that same time, the centers received only 23 telephone calls for triage at night, and only 13 were readmitted.
"We have proved beyond a shadow of a doubt that we can handle these patients without any great exacerbation," Daniel-Lemoine says.
[Editor’s note: The psychiatric nursing Outcomes Planner is one of five available from the VNS. For more information, contact the Visiting Nurse Service of Greater Woonsocket at (401) 769-5670.]
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