role as a clinical nurse specialist (CNS)/adult nurse practitioner (ANP). The advanced practice nurse with a CNS/ANP degree can have a significant impact on healthcare by preventing chronic illness and pro- moting healthy lifestyles and influ- ence the delivery, cost, and quality of healthcare to persons with chronic illness.2
Background of CHF
The AACN Synergy Model for Patient Care describes a framework for nursing practice. The key to this model is the linkage of patient char- acteristics with nurse competencies to achieve optimal patient out- comes.1 The Synergy Model is readily adaptable to the acute care or critical care setting when the patient is criti- cally ill and the intensive care nurse links his or her own competencies to the patient's characteristics. How- ever, not all acute care is conducted
Sonya Hardin is an assistant professor and coordinator of the MSN/MHA pro- gram at the School of Nursing, University of NC at Charlotte, NC.
Leslie Hussey is an associate professor at the School of Nursing, Chair Adult Health Nursing Department, University of NC at Charlotte.
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within the walls of the hospital set- ting. Today's healthcare environment mandates that patients with serious diseases live in their homes, causing the need for acute and critical care settings to reach out to their patients not only to assist them in maintain- ing a quality of life but also to decrease costs of hospital readmis- sions. This situation is especially true for patients with chronic heart failure (CHF). In the United States, many patients with CHF regularly visit CHF clinics that are run by advanced prac- tice nurses; these clinics assist patients with maintaining and often improving their state of heart failure, while also proving cost-effective.
The Synergy Model provides the framework for nurses to manage complex clients experiencing acute exasperation of their illness and to work toward reducing the trajectory of the illness. The purpose of this article is to discuss the application of The Synergy Model to an ambula- tory CHF clinic. We will discuss the characteristics of a patient who visited a local clinic, with the advanced practice nurse holding a CHF is a major public health problem; it is the most common diagnosis for people older than 65 years of age who are discharged from hospitals. CHF is a progressive and chronic disease that limits patients' functional status and severely lowers their quality of life. Currently, CHF is the number one diagnosis of Medicare beneficiaries, costing $10 to $30 billion annually.3
Although significant advances have been made in determining both the pathophysiology and therapy for CHF, there has been surprisingly lit- tle change in mortality rates over the past 4 decades.4 The 5-year mortality rate for patients with symptomatic heart failure is almost 50%, and up to 40% of these deaths are sudden.5
CHF not only increases mortality but also has a dramatic effect on patients' functional ability and qual- ity of life. Nearly 1 million patients with CHF cannot live their lives without some restriction on activity because of the signs and symptoms of heart failure.6
Data indicate that between one third and one half of heart failure readmissions, particularly those
CRITICALCARENURSE Vol 23, No. 1, FEBRUARY 2003 73
occurring within 90 days, are pre- ventable.7 Factors that contribute to preventable hospitalizations are inadequate patient and caregiver education, poor symptom control, insufficient social support, and inadequate discharge planning.8
Successful management of people with CHF often includes long-term lifestyle adjustments by patients and families. Lifestyle adjustments focus on modifications in diet and activi- ties, adherence to a complex medica- tion regimen, and the need to monitor symptoms. The success of lifestyle adjustments depends not only on the person with CHF but also on his or her social support.8
In the early stages, patients with heart failure may have minimal physical limitations and symptoms. In later stages, ordinary daily activi- ties become difficult, even at rest. Typically, the first key indicator of transition from early- to late-stage CHF is hospital admission. Unfortunately, both physical and psychosocial interventions typically become aggressive only during the late stages of heart failure, which is usually too late to significantly affect mortality. This delay of intervention is partly due to the fact that patients in early stages of CHF do not seek medical treatment until their condi- tion requires hospitalization.
Because of the incidence and cost of CHF, many organizations have developed innovative specialized clinics managed by advance practice nurses to provide intensive outpa- tient ambulatory care for the CHF population. These clinics were formed to enhance the appropriate use of therapies and to bring about desired health maintenance and decreased rehospitalization. Such clinics typically provide primary care, counseling, education, and intensive follow-up. Numerous stud- ies show that improved outcomes can be obtained through such nurse- managed clinics.9,10
Most CHF clinics operate within the outpatient setting, near a hospi- tal. Criteria for admission to such clinics include but are not limited to: ejection fraction of 0.40 or less, New York Heart Association class II to IV as determined by a physician, read- mission to the hospital 1 or more times in the past year, and a history of CHF. These clinics are managed by advanced practice nurses who are either CNSs or ANPs and who are the primary providers of care in con- sultation with the medical director of the clinic.
Patients attend the clinic from twice a week to once a month; they are reassessed at each visit and eval- uated for continued therapies and education. Advanced practice nurses are excellent candidates to manage this complex population. Their interventions can result in a decrease in the readmission rate and an improved quality of life. Through their education, nurses learn to approach a patient holistically, inte- grating many aspects of care. This integration is key to the success of patient management and leads to positive outcomes. Readmission of CHF, along with resultant costs of hospitalization is decreased. Patient involvement in treatment demands the skill, expertise, and education of the nurse, not only in the initial assessment, but also in the ongoing coaching process. Advanced practice nurses today, and increasingly in the future, will become primary care providers for this important group of patients. Nurse-based models of care must be tested to determine their effectiveness and generalizabil- ity to recipients of healthcare.
Sophie, an 82-year-old African-American woman, had New York Heart Association class III CHF. She was a widow, lived alone, and her sole financial support was Social Security. She had been hospitalized twice in the past 18 months for exac- erbations of CHF. She had had a stroke, which had left her dependent on a cane for ambulation. She had hypertension, osteoporosis, atrial fib- rillation, and diabetes mellitus type
2, which was controlled with diet; also, she took oral hypoglycemics. Sophie had a daughter who cared about her but was unable to provide any supplemental financial support.
Sophie took the following med- ications: an angiotensin-converting enzyme inhibitor, digoxin, potassi- um, fosinopril sodium, coumadin, and furosemide. Her medications cost her approximately $350 per month. Because she did not have any other insurance except Medicare,
Sophie payed for medications herself. She did not drive but used public transportation to travel to the clinic and for other trips such as going to the grocery store and church. Sophie came to the CHF clinic every 2 weeks.
On the morning of one visit, Sophie was complaining of slight shortness of breath. She had gained
3 lb since her last visit. Her blood pressure was elevated to 176/94 mm Hg -- it was normally around 130/80 mm Hg. Her pulse was 106 beats/min and irregular, and she stated that her shoes did not fit so she had to wear her slippers. Her 74 CRITICALCARENURSE Vol 23, No. 1, FEBRUARY 2003
random blood glucose level was 13.6 mmol/L (245 mg/dL).
Table 1 Sophie's patient characteristics
Upon questioning Sophie, the advanced practice nurse found that Sophie had not taken any of her medications for the past 3 days. Sophie was reluctant to answer questions because she did not want to "get into trouble" with the doc- tors. After further questioning, Sophie admitted that she had run out of medications 3 days earlier because she did not have the money to pay for them. She also was not eating well, again because of the lack
Stability (decreasing) Complexity (increasing)
Predictability (uncertain) Resiliency (good potential) Vulnerability (increased) Participation in decision
making and care
Blood pressure and pulse, presence of pedal edema, dyspnea
2 or more body systems became entangled, cardiopulmonary systems were compromised, the patient was impacted by resource availability
Decreased stability and complexity cause uncertainty in the patient's life
Willingness and knowledge to comply with treatment…