Running head: EXECUTIVE SUMMARY 1

Executive Summary

Kristine Krumdiack and Katherine Sellards

Julie French, DNP, RN

NURS443 Interdisciplinary Care Coordination Practice Experience

Summer Quarter 2017

Western Washington University RN-BSN

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Purpose Statement

The Care Coordination project was conducted by a team of WWU nurses in conjunction
with Peace Health Cardiothoracic Surgeons and Kimberlee Einfeld, MN, RN. All organizations
within the Peace Health system are driven by the main mission of we carry on the healing
mission of Jesus Christ by promoting personal and community health, relieving pain and
suffering, and treating each person in a loving and caring way. The purpose of the partnership
for Care Coordination was to observe this organizations efforts to improve the patients
experience and transition across the care continuum while supporting in the preparation for a
trans-catheter aortic valve replacement (TAVR). In this summary, we will discuss qualifications
for a TAVR procedure, observations noted during the practice experience, patient specific
findings and recommendations to participate at this practice site for future WWU RN-BSN
cohorts.

Problem Description

TAVR candidates are referred to Peace Health Cardiothoracic surgeons by either the
primary care physicians or primary cardiologist because of a diagnosis of severe aortic stenosis.
Candidacy of a TAVR procedure is determined by consultations with two cardiothoracic
surgeons and a series of diagnostic testing to evaluate if the patient can undergo an open-heart
valve replacement versus a trans-catheter approach. Many things are taken into consideration
during this process such as a frailty assessment, comorbidities, echocardiogram indicators and
other diagnostic exams. Once the determination is made that the patient is an acceptable
candidate for a TAVR procedure, care coordination continues through until 30 days post surgery
with a handoff back to the primary care provider.

Method

During this practice experience, we were able to observe the full spectrum of care
coordination in this organization. We attended several pre-operative appointments, viewed an
informational video, consulted with a Mended Hearts representative that offers post operative
support to cardiac patients, sat in on a one week post operative open-heart valve replacement
check up, over-heard care coordinator-patient phone calls, viewed a TAVR procedure and spent
the afternoon with patients and therapists at cardiac rehabilitation. Do to the unique complexity
of these patients the care coordination model that is currently in use at this facility is based off of
the concepts of the perioperative home model. This model supports patients in perusal of
treatment in preparation for surgery, during the hospital stay and throughout recovery.

Key Findings

Findings from this experience included the differences in types of familial support
ranging from extended family support to limited. There were some concerns with post-operative
care and coordination of cardiac rehabilitation related to travel distance. Emotional support was
also a factor regarding issues that were experience by the patient intraoperatively. However, the
care coordinator assists the patient with these issues by frequent contact post-procedure to
evaluate recovery and address any medical concerns, assist with locating nearest cardiac
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rehabilitation facilities and also participates in therapeutic communication to alleviate issue

experience by the patient during the procedure.

Recommendations

We have no recommendations in improving the care coordination model used within this
practice or in regards to the practice experience as a whole. We believe that the Perioperative
Surgical Home (PSH) model embraces all aspects of care coordination in order to provide for
quality care, positive patient experience and improved patient outcomes. We were able to
observe a good portion of the coordination of care within the time allowed for this experience
and recommend that future cohorts observe the procedure based on patient availability.

Conclusion

Positive implications noted during this practice experience include how involved the
office staff and care coordinator is during the process to assure follow through of all
appointments and diagnostic exams are performed. However, it is important for the care
coordinator to be able to evaluate the patients understanding of when to notify the office with
any post-procedure questions or concerns.
The ANA Framework for Measuring Nurses Contributions to Care Coordination guides
the nurses role as a care coordinator with emphasis on a high level of patient-centered care that
promotes for a good patient experience and improving patient outcomes. There is no one thing
that will guide a care coordinator in their efforts in directing patients down the path from care to
recovery. There are many available resources to assist them but it is evident that there is a needed
passion for this work. The passion to improve the patients experience, provide quality care and
dedication to the coordination efforts were evident in this practice experience. We as students
were guided, as were the patients we followed, through a complex system of care that most fear
even long before they have entered it.
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Reference

American Nurses Association. (2013). Framework for measuring nurses contributions to care

coordination.