Together with the multidisciplinary team, the NP identified HF patients to be admitted to the program.
"We looked at those that we could catch early in the disease, " Kutzleb says. "By having patient engagement, they 're going to learn how to self-manage, and they 're going to have a better longevity with a chronic disease. "
The NP then met the patient and family, introduced herself and her role, and provided basic patient education in the hospital. They made post-discharge follow-up appointments with the patient for more intensive education sessions, as well as confirming the patient had follow-up appointments with the necessary physicians.
The NP worked with the physician on the care plan, made sure all diagnostic tests and reports were completed, medications were stable, and that the discharge plan was put into action.
After the patient was discharged, the NP connected with the patient by phone within 24 to 48 hours.
During the first NP follow-up visit, the patient received a full physical assessment and a full educational session with along with a family member or support person. The NP reviewed diet, daily weights, and set the patients up with a medication management tool that allows the NP to optimally schedule the patient 's medications.
"By planning the medications throughout the day, they didn 't take all the medications all at once and then felt too tired to do anything else, " Kutzleb says. "It became a routine and then became inherent in their daily schedule. We gave them a printout and we were able to update that printout at any given time. It was successful, we had a tremendous drop in recidivism. "
The drop in recidivism went beyond the initial 30-day discharge period. The 60-day and 90-day readmission rates for the group receiving care through the model were 4% and 3% compared to 27% and 29% in a group receiving typical care.
Because of these significant results, advanced practice providers are being added to more of the medical center 's service lines including cardiology, chronic care management, oncology, and genetics.
The model 's success also helped Kutzleb make the case to deliver APRN provided care beyond the hospital walls.
"I was successful in writing a business plan and got approval from the physician oversight committee and opened the first fully run nurse practitioner primary care practice in Bergen county, " Kutzleb says.
With the old fee-for-service model transitioning to one focused on value-based care, Kutzleb says healthcare delivery will need to evolve as well.
"Healthcare is changing and for all its pluses and minuses, it needs to change. It wasn 't really ever meeting the needs of the patient. "
Jennifer Thew, RN, is the senior nursing editor at HealthLeaders.