Introduction
Chronic care management (CCM) is a critical component of primary care which aims to manage conditions in non-acute stages and promote better health. It ensures that patients receive recommended preventive care services and other health-related oversight such as medication management. Over the past few weeks, clinical logs were documented, which tracked my understanding of CCM and its aspects in advanced nursing and healthcare provision.
Narrative
- Developing comprehensive CCM plans and access to a multidisciplinary health team allows patients to achieve health management goals and maintain disease control. Care coordination is critical and also contributes to patient support both at and in between outpatient visits.
- The vital elements of the CCM toolkit consist of the delivery system design, care coordination, and self-management support. The delivery system must provide an efficient channel of clinical care through planned patient interactions. Care coordination should include effective workflow and careful collaboration among involved team members and social support services if applicable. Finally, self-management empowers and prepares patients to oversee their healthcare with knowledge and practice when at home.
- CCM follows a specific set of steps which provide a structured approach and help address challenges. Step 1 is the identification of patients, commonly with two or more chronic conditions. Step 2 is educating and enrolling patients, gaining consent, and familiarizing them with the program. Step 3 is ensuring patient engagement through systematic assessment and compiling a comprehensive care plan. Step 4 is incorporating an automated documentation tool that allows tracking paperwork, reimbursements, and patient data. Finally, Step 5 is billing and reimbursement; it is vital to validate that patient requirements have been met.
- Implementation of CCM by providers consists of tailored methods that target individual patient needs based on person-centered care. Only practices that meet specific requirements can bill for CCM services, and these services need to be improved consistently. Finally, for each patient receiving CCM services, a comprehensive assessment and care plan is developed that incorporates health issues and medical or psychosocial issues. The provider is attempting to engage the patient actively. Patients are provided with communication and support to healthcare professionals to assist in managing a chronic disease.
- There are requirements for patients as well participating in CCM. For example, they can only receive it from one provider, and it requires full consent. Consulting patients are also highly critical in the involving implementation and can both provide insights and encourage patients to participate in their care.
- Implications of the project were discussed with a focus on DNP Essential IV. Some major issues included inadequate funding or a lack of positive financial implications. After conversations with staff, many were optimistic regarding adopting a toolkit for caring for patients with chronic diseases, particularly in managing co-morbidities. Clinics are typically highly selective in implementing new changes and projects. In order to succeed, mine had to demonstrate objective benefits for the organization.
- Staff readiness for the adoption of a new care coordination model was discussed to fulfill DNP Essential II. Application of new care models is a complex staff and organizational task that also calls upon understand and engagement from the workforce. The change is best implemented when stemming from leadership, and through the discussion, I had the support of the administration and nurse management.
- Implementing the project meant it was necessary to identify and understand the requirements of a CCM toolkit for service providers. Based on academic research and practical exploration, it became evident that knowledge and skill gaps had to be filled among the staff for competent implementation. Training sessions, as well as care coordination established by the nurse manager, can aid in preparing staff for the transition. Furthermore, best evidence-based practices are effective in filling knowledge gaps to ensure success.
- One of the primary aspects of care coordination is sharing information that I evaluated on an informal level at the clinic. Information sharing is vital to patient-centered care to ensure care delivery based on the same protocols, agreed-upon treatments, and values. It became noticeable that communication and information sharing were struggling in some aspects, which in turn adversely affected service quality. By organizing a nurse meeting, some strategies of enhanced information sharing were discussed, and everyone was brought to the same level in working together to establish the exchange of information in the coordinated care aspect.
- In the final week, the development of a CCM toolkit was explored with its initial steps. Some important elements are a CCM staff workflow chart to manage staff assignments and the CCM enrollment phase, which consists of introducing patients, getting their consent, and engaging them in the program. Of course, then patients are evaluated, and all information is gathered on an easily shared ID card. Then, a comprehensive care plan is developed, which includes both short- and long-term actions and achievements based on patients’ individual needs.
Five Pillars
Throughout the weeks of clinical experience and implementing this project, I believe I have directly and indirectly touched upon the majority of the Five Pillars of Nursing. Professionalism in nursing is complex but can be defined by elements such as attitude and conduct on the job and provision of top-quality care to patients, upholding values such as respect, dignity, accountability, and integrity, as well as upholding certification and using the latest evidence-based research (Cusack et al., 2019). The CCM initiative is an example of professionalism by attempting to improve patient care through an evidence-based method, taking the time to develop the toolkit fully, work with other staff and managers, and approach it from a fully competent perspective. According to Adib-Hajbaghery & Sharifi (2017), critical thinking is an essential skill in nursing. This mental process skillfully allows one to perceive, analyze, synthesize, and evaluate information through observation, research, and experience. In the implementation of this project, I had to rely on critical thinking strongly. Not only was I acquiring new knowledge regarding CCM, but I was also in the process of practically applying it in a clinical setting. That included determining eligibility, identifying gaps in knowledge, finding solutions, and other aspects that saw my work with literature and leadership for the best outcome – demonstrating critical thinking.
Communication is practically a fundamental nursing skill, vital and utilized in virtually all areas, communication with patients, staff, co-workers, handovers, treatment, education, health promotion, and many others (Abdrbo, 2017). Communication was a concept deeply explored within the weekly logs and experiences. This includes the role of communication in CCM with patients and engagement, communication with staff regarding introduced changes, and discussions with management and administration regarding best practices to implement CCM. Each required a different approach and perspective regarding professional communication but strongly contributed to personal versatility and development. The other two pillars of holism and caring were also touched upon as CCM is inherently a holistic program with patient-centered care at heart. In the implementation context, these concepts were reviewed and practiced as CCM aims to aid patients struggling with chronic conditions, providing new means of help and management in outpatient settings.
Reflections
The weekly logs and my general experience relayed in this paper demonstrate a process of extraordinary professional growth for me as a nurse. It was a significant undertaking which required a multifaceted, complex approach to developing and integrating a CCM toolkit in a clinical facility. I believe that the weekly logs present elements of progress in many ways. First, I just familiarize myself with CCM and its importance in clinical and patient-centered care. Then I sought out the viability of implementing CCM at my workplace, working with nurse managers and administrators. I explored the attitudes of staff and areas of improvement that needed to be made. Afterward, I learned about the development of CCM toolkits and implementation.
The future of nursing is undoubtedly a highly professional, multifaceted position that supports and oversees the majority of primary care. There is extensive progress in the model’s professionalism and skills expected from nurses (Graebe & Chappell, 2019). To achieve this requires progress in learning and practical experience, fundamental to my professional development in advanced care nursing. As evident by the logs, the project also helped to meet several key course and program objectives via DNP essentials. I have become more independent, forward, and critical thinker learned the importance and skills for multidisciplinary professional communication, and acquired experience developing a nursing evidence-based intervention. I hope to use this experience to further progress my nursing knowledge and professionalism in clinical.
References
Abdrbo, A. (2017). Assessment of nursing students’ communication skills. Nursing Education Perspectives, 38(3), 149–151. Web.
Adib-Hajbaghery, M., & Sharifi, N. (2017). Effect of simulation training on the development of nurses and nursing students’ critical thinking: A systematic literature review. Nurse Education Today, 50, 17–24. Web.
Cusack, L., Drioli-Phillips, P. G., Brown, J. A., & Hunter, S. (2019). Re-engaging concepts of professionalism to inform regulatory practices in nursing. Journal of Nursing Regulation, 10(3), 21–27. Web.
Graebe, J., & Chappell, K. (2019). Looking back and leaping forward—A reflection on the evolution of nursing continuing professional development credentialing. The Journal of Continuing Education in Nursing, 50(12), 531–533. Web.