Implementation of Family Planning and Contraception for Female Inmates in Vermont

Background and Objective(s): Unplanned pregnancies are disproportionately high among female inmates, and incarceration provides a unique opportunity for care may be otherwise difficult to obtain, including reproductive health and family planning services, specifically the provision of contraception. It is known that women are 14 times more likely to initiate contraception if education and services are provided within the prison (Clarke et al., 2006b). Despite decades of research identifying the unmet need, very few prisons around the country provide any sort of sexual health or family planning care to prisoners (Braithwaite, Treadwell, & Arriola, 2008). Methods: This project involves the creation of new program and implementation of a new model of care within the existing health care structure at Vermont’s sole women’s prison, Chittenden Regional Correctional Facility (CRCF). First, determination of the most appropriate model of care; second, building a curriculum based on existing evidence-based practice guidelines; and third, implementation of the program using a one-year pilot program. Quality metrics, as yet undetermined and beyond the scope of this project, will need to be monitored throughout the year by the research and quality team within the prison to measure impact of the new program. Results: Partnership with the Vermont Department of Justice, Department of Corrections, Centurion Health, and Planned Parenthood was necessary for completion of the project. A one-year pilot program begins June 2017, including group and individual education sessions and coordination with staff to expand family planning services within the existing health care clinic, as well as a referral system for care outside of the scope of the clinic. Implications: Despite decades of research demonstrating the need and female inmates desire to obtain contraception before discharge from prison, multiple barriers to accessing care still exist, making reproductive services limited in U.S. women’s prisons. The pilot program will serve as a model for other prisons, and quality measures throughout the year will be vital in demonstrating the success of the program. Extreme attention to ethics and adaptations appropriate to working with a vulnerable population of imprisoned women were central to the completion of this project

Diabetes Type II Quality Improvement Using the My Own Health Report

Diabetes Mellitus Type II Quality Improvement Using the My Own Health Report Lynn Bennett McMorrow Rationale: To maintain Primary Care Medical Home status, Cold Hollow Family Practice (CHFP) is mandated to perform continuous quality improvement for chronically ill patients. To achieve this goal at CHFP, a formal quality improvement (QI) process using a validated health risk assessment tool, My Own Health Report (MOHR) was used to engage patients with Type 2 Diabetes (T2D) in dialogue regarding self change behaviors. The goal was to improve patient self-care management as evidenced by decreased HbA1c readings or weight as compared to non-participating patients, over a six-month period. From 1980 through 2012, the number of adults with diagnosed diabetes in the United States nearly quadrupled, from 5.5 million to 21.3 million and 1.7 million more persons over 20 years of age are diagnosed each year. The estimated direct medical costs in 2012 were 176 billion and the indirect costs (lost wages, disability and death) for the same time frame were 69 billion. Individualized patient care, as the corner stone of evidence based practice, is vital to improve self-management in patients who have Type 2 Diabetes (T2D). Methods: The QI process began with 27 patients. We had 10 patients who did not participate and 17 who did the MOHR as administered by the medical assistant. The provider reviewed the MOHR summary and used motivational interviewing to discuss the results with each patient scheduled for a T2D visit, for willingness to discuss or change modifiable life styles. Quantitative analysis was done with Fisher’s Exact Test comparing those who were in the MOHR group to those not participating. Qualitative analysis was not done secondary to time and EHR constraints. Results: Comparison of the MOHR group to the non-MOHR group, 47% improved both weight and HbA1c whereas the non-MOHR group had 0% improvement (P=0.01). Using the same comparison in HbA1c only, the MOHR group decreased by 58% compared to 10% for the non-MOHR group (P= 0.02). Conclusions: Generalizability is limited by a number of factors: a small group study of 27 patients and provider use of motivational interviewing and historical patient/provider relationships. Furthermore, it was a self-selected group that may have been ready to change. Without randomization, motivational interviewing, and requiring that the MOHR be completed we cannot absolutely determine the impact of the MOHR on T2D disease marker improvements. Further study using the MOHR report with motivational interviewing is needed to support these findings. Keywords: Diabetes Type 2, MOHR, HbA1

Establishing a Nurse Practitioner Residency Program in a Rural Federally Qualified Health Center: A Feasibility Analysis and Pilot Study

Abstract Rural communities are disproportionately underserved and have been identified as a priority population to improve health outcomes and access to care (Agency for Healthcare Research and Quality [AHRQ], 2015). National organizations have recognized a deficit in primary care providers, recommended nurse practitioners (NPs) as a solution, and supported NP residency programs as a means to prepare and recruit qualified practitioners into communities (Institute of Medicine [IOM], 2010; The Patient Protection and Affordable Care Act [PPACA], 2010). However, there are only three primary care NP residency programs in rural California (National Nurse Practitioner Residency and Fellowship Training Consortium [NNPRFTC], 2015). A pilot NP residency program and feasibility analysis was designed to evaluate current program structures and funding sources while promoting the development and implementation of NP residency programs within rural Federally Qualified Health Centers (FQHCs). Evaluation metrics included competency self-assessments, content-based evaluations of a web-based didactic module, and qualitative program evaluations. The results of this pilot study showed an increase in self-reported clinical competence as well as knowledge acquisition with the didactic module. An opportunity exists to model new NP residency programs off the pilot activities and structures identified in this project within rural FQHCs

LARC Method Appropriateness in Substance Use Treatment: A Quality Improvement Project for Integrated Care

Problem: Individuals with substance use disorder (SUD) have disproportionately higher rates of unintended pregnancy when compared to the general population, estimated to be 85% (Heil et al., 2011). Not only are poor maternal and fetal outcomes associated with unplanned pregnancies, but pregnancies in women with SUD are further complicated by additional risks and adverse outcomes (Black & Day, 2016). Context: Addiction treatment centers and programs are primed with opportunity to offer family planning services, when contact with medical providers is increased for substance use treatment. In response to the opioid crisis and unprecedented rates of unintended pregnancy, this project was designed to identify, develop, and implement an evidence-based approach to integrate birth control education and services, emphasizing long-acting reversible contraception (LARC) in substance use treatment. Interventions: A two-part interdisciplinary training was designed to include best practice recommendations regarding LARC utilization and comprehensive contraceptive counseling, hands-on skills training with vaginal simulators, and subdermal implant training and certification. Measures: A pre/post training assessment was utilized to assess change in provider confidence and readiness in offering contraceptive counseling, as well as, performing LARC procedures in preparation for service integration on site. Results: Through data analysis, results indicated a 33.33% increase in provider comfort in providing contraceptive counseling and confidence in identifying LARC eligible candidates. The greatest changes were seen in provider self-assessed preparedness in providing counseling regarding LARC safety and efficacy, with a 44.44% increase, and a 57.89% increase in provider comfortability with the Nexplanon insertion and removal procedures compared with pre- training assessments. Conclusions: Didactic and hands-on training are effective approaches to prepare providers for service expansion to include contraceptive services at addiction treatment centers

Effectiveness of EHR-Depression Screening Among Adult Diabetics in an Urban Primary Care Clinic

Background Diabetes mellitus (DM) and depression are important comorbid conditions that can lead to more serious health outcomes. The American Diabetes Association (ADA) supports routine screening for depression as part of standard diabetes management. The PHQ2 and PHQ9 questionnaires are good diagnostic screening tools used for major depressive disorders in Type 2 diabetes mellitus (DM2). This quality improvement study aims to compare the rate of depression screening, treatment, and referral to behavioral health in adult patients with DM2 pre and post-integration of depression screening tools into the electronic health record (EHR). Methods We conducted a retrospective chart review on patients aged 18 years and above with a diagnosis of DM2 and no initial diagnosis of depression or other mental illnesses. Chart reviews included those from 2018 or prior for before integration data and 2020 to present for after integration. Sixty subjects were randomly selected from a pool of 33,695 patients in the clinic with DM2 from the year 2013-2021. Thirty of the patients were prior to the integration of depression screening tools PHQ2 and PHQ9 into the EHR, while the other half were post-integration. The study population ranged from 18-83 years old. Results All subjects (100%) were screened using PHQ2 before integration and after integration. Twenty percent of patients screened had a positive PHQ2 among subjects before integration, while 10% had a positive PHQ2 after integration. Twenty percent of patients were screened with a PHQ9 pre-integration which accounted for 100% of those subjects with a positive PHQ2. However, of the 10% of patients with a positive PHQ2 post-integration, only 6.7 % of subjects were screened, which means not all patients with a positive PHQ2 were adequately screened post-integration. Interestingly, 10% of patients were treated with antidepressants before integration, while none were treated with medications in the post-integration group. There were no referrals made to the behavior team in either group. Conclusion There is no difference between the prevalence of depression screening before or after integration of depression screening tools in the EHR. The study noted that there is a decrease in the treatment using antidepressants after integration. However, other undetermined conditions could have influenced this. Furthermore, not all patients with positive PHQ2 in the after-integration group were screened with PHQ9. The authors are unsure if the integration of the depression screens influenced this change. In both groups, there is no difference between referrals to the behavior team. Implications to Nursing Practice This quality improvement study shows that providers are good at screening their DM2 patients for depression whether the screening tools were incorporated in the EHR or not. However, future studies regarding providers, support staff, and patient convenience relating to accessibility and availability of the tool should be made. Additional issues to consider are documentation reliability, hours of work to scan documents in the chart, risk of documentation getting lost, and the use of paper that requires shredding to comply with privacy

Reducing Antibiotic Use in Pediatric Upper Respiratory Infection: A Multifaceted Parent-Clinician Approach

The goal of this QI initiative was to decrease inappropriate antibiotic for the treatment of pediatric upper respiratory infection (URI) in the retail clinic setting. The approach included the use of a protocol to treat viral upper respiratory illness, a visual aid decision-making tool for guideline adherence, prescription pad for nonprescription remedies, and shared decision-making techniques for providers to involve patients and parents in management plans regarding nonprescription remedies, supportive treatment, and signs and symptoms that would warrant a return visit. An improvement trend during the first 3 months of the initiative showed a shift in antibiotic avoidance from a baseline avoidance rate of 66% to a post intervention rate of 82%. The antibiotic avoidance initiative proved to be an effective approach in reducing the rate of inappropriate antibiotic treatment for pediatric viral upper respiratory conditions

A Case Study on Pulmonary Embolism

Jacqueline Lewis (left) & Mini George (right) pictured.https://openworks.mdanderson.org/aprn-week-22/1015/thumbnail.jp

Ethical Dimensions within Qualitative Research

Throughout history people have relied on their culture for healing practices and ways of caring. Healing began in Africa thousands of years ago with herbs and plants that were used for healing and rituals. As African people came to America they brought with them cultural ways which were practiced throughout slavery. Thereafter, elders passed down the healing remedies until today. The purpose of this study was to discover beliefs, meanings, and practices of healing with botanicals (plant, root, or bark parts) recalled by African American women 80 years of age or older that were born and resided in the Mississippi Delta. The goal of the study was to provide insight into the cultural beliefs and ways of the people by identifying generic practices of the elders; thereby, providing additional knowledge needed to design and implement culturally congruent care. The knowledge obtained is posited to assist other nurses in the care of African Americans and highlight the importance of generic care awareness. This study discovered that the elders in the Mississippi Delta depend now on professional care and less on the remembered botanical healing ways of the past. Many botanical healing methods were remembered but few used today. However, women remain the healers in the family units and are considered important in care. African American elders view God as the center of life and healing. Health was defined by the elders and younger informants as the ability to get up and do normal things and is maintained by taking care of oneself. Illness is viewed as the inability to do normal activities. This finding may shed light on the late presentation of symptoms in health care within this culture. As population demographics shift, people and nurses are more mobile now than ever before. Because of this mobility, cultural care research is important to ensure provision of culturally competent care. This research provides additional resources toward understanding the elder African American culture in the Delta as it relates to provision of culturally congruent care. Ultimately, through culturally competent care, the client will receive care that is respectful, safe and not offensive