Accountability for Care Delivery and Self-Care Management

Introduction

Advanced Practice Registered Nurses (APRNs) play a pivotal role in enhancing patient self-care management through coordinated efforts that promote effective communication, goal-setting, and the development of actionable plans. The principles outlined by the Agency for Healthcare Research and Quality (AHRQ, 2020) and the Joint Commission provide a framework for APRNs to engage in self-management support (SMS) effectively. This paper describes how APRNs can involve themselves in various self-care management activities, identifies the most appropriate APRN roles for each activity, outlines specific interventions, and connects these interventions to the relevant self-care management principles.

Involvement of APRNs in Self-Care Management Activities

1. Gather Clinical Data Before a Visit

APRNs Role: Nurse Practitioner (NP)

Nurse practitioners can gather comprehensive clinical data before patient visits through pre-visit questionnaires or electronic health record (EHR) reviews. This process may involve assessing medication adherence, recent lab results, and vital signs to ensure a holistic understanding of the patient’s health status prior to the appointment.

Intervention: Utilize standardized pre-visit assessment tools that patients complete online or via secure messaging. This enables NPs to review critical information ahead of time, allowing for a more focused conversation during the visit.

Supporting Principle: Evidence-based information is used to guide patient-clinician discussions and shared decisions.

2. Set Agendas for Patient Visits

APRNs Role: Clinical Nurse Specialist (CNS)

Clinical nurse specialists can facilitate agenda-setting by collaborating with patients to identify their primary concerns and expectations for the visit. This collaborative approach ensures that the session addresses the patient’s most pressing issues.

Intervention: Implement structured agenda-setting techniques, such as the use of open-ended questions and reflective listening, to empower patients to articulate their needs effectively.

Supporting Principle: Patients and clinicians collaboratively prioritize & set goals & action steps.

3. Help Patients Set Health Goals

APRNs Role: Certified Nurse Educator (CNE)

Certified nurse educators can assist patients in setting realistic health goals based on evidence-based guidelines and individual health assessments. They can provide educational resources tailored to each patient’s unique needs and circumstances.

Intervention: Employ motivational interviewing techniques to engage patients in discussions about their aspirations, ensuring that goals are specific, measurable, achievable, relevant, and time-bound (SMART).

Supporting Principle: Patients work on SMS with several members of the healthcare team; the commitment to SMS is practice-wide.

4. Develop Action Plans for Achieving Goals

APRNs Role: Advanced Practice Case Manager

Advanced practice case managers can create detailed action plans that outline specific steps patients need to take to achieve their health goals. These plans may include referrals, lifestyle changes, medication adjustments, and scheduled follow-ups.

Intervention: Use care planning software integrated with EHR systems to document action plans clearly. This documentation can be shared with all team members involved in the patient’s care to ensure consistency.

Supporting Principle: Clinical and health behavior assessments are brief and targeted.

5. Track Health Outcomes

APRNs Role: Nurse Executive

Nurse executives can implement systems for tracking health outcomes across patient populations. They can oversee data collection efforts and analyze trends to assess the effectiveness of SMS interventions.

Intervention: Develop a dashboard that aggregates health outcome data from various sources, enabling real-time monitoring of patient progress towards their goals.

Supporting Principle: The healthcare team provides timely, active follow-up.

6. Refer Patients to Community Programs

APRNs Role: Certified Nurse Informaticist

Certified nurse informaticists can leverage technology to identify community resources that align with patients’ needs. They can ensure that relevant information is available within EHR systems for easy access by healthcare providers.

Intervention: Create a resource database that includes local community programs for chronic disease management, wellness initiatives, and support groups, which can be linked directly from the EHR system.

Supporting Principle: Patients are linked to evidence-based community programs.

Conclusion

APRNs have a vital role in fostering effective self-care management through various activities that enhance patient engagement and accountability for care delivery. By clearly defining their roles across different competencies and employing targeted interventions, APRNs can improve health outcomes for their patients. The connections made between these activities and the self-care management principles underscore the importance of a cohesive approach to patient care that prioritizes collaboration, education, and community resources.

References

1. Agency for Healthcare Research and Quality. (2020). Effective Self-Management Support. Retrieved from AHRQ
2. Battersby, M., et al. (2010). Principles of Patient Self-Care Management. The Joint Commission Journal on Quality and Patient Safety, 36(4), 145-154.
3. McGonigle, D., & Mastrian, K. (2017). Nursing Informatics: Scope and Standards of Practice (3rd ed.). American Nurses Association.

This paper outlines how APRNs can actively engage in self-care management while identifying appropriate roles, interventions, and supporting principles from established guidelines.