Ambulatory Care Management - Need of the Hour


 
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Ambulatory Care

Ambulatory Care is any non-emergency or outpatient medical care delivered at a clinic, physician's place or hospital for medical conditions that do not require hospital admission. Medical investigations performed on an ambulatory basis include blood tests X-rays endoscopy and even biopsy procedures of superficial organs. Ambulatory Care is delivered at Physician's place or Urgent Care Centers designed to evaluate and treat conditions that are not severe enough to require treatment in a hospital emergency department but still require treatment beyond normal physician office hours or before a physician appointment is available. Over 15,000 Ambulatory Care Centers deliver Urgent Care in the United States even in Cardiology, Obstetrics and Gastroenterology.

The Problems

Inappropriate medications prescribed by office-based physicians for patients (Aparasu and Fliginger,1997) linked to a large share of adverse drug reactions and to excess health care utilization (Goulding, 2004), repeat prescriptions (Peter, 2004), shifting care from physicians to nurses (Laurent et.al, 2008),establishment of nurse-led clinics in complex care situations like Cancer Care (Loftus et.al, 2001) and cost benefits of ambulatory care with reference to inpatient care (Berk and Chalmers, 1986) have created a need to effectively regulate and manage ambulatory care settings. Utilization guidelines assist in the planning balancing and preservation of the critical elements of Ambulatory Care facilities (Pauly and Jellinek, 2005). Further, in Ambulatory Care settings where two or more health care professionals are involved in care, most of the patients are not clear on the professional in charge and the one accountable (Wasson, 2008). Studies have shown that problems in the Ambulatory Care are strongly related to trust, changing professionals and communication of health information (Keating et.al, 2002). A study to compare the existing measures of provider continuity in Ambulatory Care to assess differences and limitations in such care settings have shown a need for further development and refinement of continuity measures (Steinwachs, 1979).  Further, previously executed advance directives are not accessible when patients are transferred from Ambulatory to Acute Care settings (Morrison et.al, 1995). Another study to examine patient-level, facility-level, and area market-level factors that affect Ambulatory Care-sensitive hospitalization rates has shown a need for continuing efforts to improve quality-of-care practices (Carter, 2003). It is true that those with the greatest healthcare needs often receive the least adequate care and this has given rise to a concept called the "Inverse Care Law," that has serious implications for Ambulatory Care outcomes among vulnerable populations including low-income patients, racial, ethnic minorities and the uninsured (Fiscella and Shin, 2005). Recent studies have indicated that inadequate financial status has a broad and adverse influence on health and healthcare. Patients with low financial status are less likely to receive good care (Wasson, 2006). Long appointment waits, lack of insurance and absence of after-hours care have been identified as factors associated with lower levels of access and continuity of Ambulatory Care (Forrest and Starfield, 1998). Diagnostic errors have been identified as important and underappreciated source of errors causing needless delays to treatment (Wahls, 2007).

Management

Studies have shown primary nursing as an important determinant of the perception of Ambulatory Care quality (Stone et.al, 2007) and appropriately trained nurses can produce a high quality care and achieve good health outcomes for patients (Laurant et.al, 2008). A crossover randomized controlled trial of cycles of quality assurance in sixteen primary Ambulatory Care group practices has shown that quality assurance interventions significantly improve quality of performance (Palmer et.al, 1985). It has been demonstrated that easily available, comprehensive, integrated electronic clinical information reduces the use of Ambulatory Care especially inappropriate visits without any compromise on quality (Garrido et.al, 2005). A study to analyse the effectiveness of an Ambulatory Care Model intervention program involving Nurse Clinicians in improving drug documentation in medical records, patient compliance and disease control in Ambulatory Care settings has demonstrated a significant improvement and associated cost reductions in drug documentation, compliance and disease control after the implementation of the intervention program (Bond and Monson, 1984).

Recent Practice Innovations

Collaborative Care is a recent concept that refers to a partnership between healthcare professionals and patients who feel confident to manage their health conditions. Examination of the association of Collaborative Care with specific measures for treatment effect, disease control, prevention and economic impacts has shown that good Collaborative Care was associated with better control of blood pressure, blood glucose level, serum cholesterol level, and treatment effectiveness for pain and emotional problems (Wasson, 2006). Ideal Micro Practice is a recent concept that facilitates sharing of new tools and approaches to understand patients' needs and increase confidence in their ability to manage clinical situations in ambulatory settings. Ideal Micro Practices deliver patient-centered collaborative care so that the patients receive care exactly as they want (Moore et.al, 2006). A planned Ambulatory Care management strategy that addresses health disparities attributed to low socioeconomic status using self-reported information from thirteen thousand two hundred and seventy one older adults from several controlled trials has revealed three strata of patients based on financial status, the presence or absence of bothersome pain or psychosocial problems and their confidence with self-care. A majority of ambulatory patients have been shown to fall in the low financial stratum (Wasson, 2006). Technology that supports patient-centered Collaborative Care is capable of bridging the gap between desirable goals and time constraints (Moore and Wasson, 2006). For example, Patient Portals enable patients to review their medical record and add information to it. Clinics have started using E-Visits as a substitute for office visits (Walters, 2006). A novel health-promotion outreach system based on electronic data queries and active patient-centered outreach that minimises patient barriers to adherence has been evaluated recently and shown to be effective in reducing the suboptimal patient care given due to poorly organized clinical information and time-limited sporadic appointments with medical care providers (Denberg et.al , 2008). A meta-analysis of published randomized controlled trials to assess the overall effectiveness of computer-based reminder systems in Ambulatory settings directed at preventive care has shown that computer reminders improve preventive practices for Vaccinations, Breast Cancer screening, Colorectal Cancer screening and Cardiovascular risk reduction (Shea et.al, 1996).

Neo-role Nurses in Ambulatory Care

Primary Care Nurse Case Managers are nurses assigned specific to patients in addition to a primary care physician. Inpatient Liaison Nurses are nurses in the outpatient prime care clinic who help bridge the gap in continuity of care, assist follow-up on referrals to ancillary services and ensure that the patient has a follow-up appointment in the prime care clinic. Nurse-Operated Outpatient Clinics are clinics, where, Registered Nurses with prior out patient clinic exposure manage the care of patients especially with diabetes, hypertension, tuberculosis and blood disorders. Wound Management Clinics managed by two Clinical Nurse Specialists are now being established for outpatient management of patients with chronic vascular ulcers and non-healing wounds (www.va.gov).

Conclusion

Nurse care is an important ingredient of quality Ambulatory Care. Technological innovations and intervention programs involving Nurse Practioners improve Ambulatory Care delivery. Nurse Operated Care Clinic is a recent trend in Ambulatory Care.

Reference

  • BarbaraWalters, DeborahBarnard and StevenParis (2006). Patient Portals" and "E-Visits". Journal of Ambulatory Care Management.29 (3); 222-224.
  • C B Forrest and B Starfield (1998). Entry into Primary Care and Continuity: The Effects of Access.American Journal of Public Health 88(9); 1330-1336.
  • C. A. Bond and R. Monson (1984). Sustained Improvement in Drug Documentation, Compliance, and Disease Control. A Four-Year Analysis of an Ambulatory Care Model.Archieves of Internal Medicine.144 (6).
  • DavidM.Mosen, JulieSchmittdiel, JudithHibbard, DavidSobel, CarolRemmers and JimBellows (2007). Is Patient Activation Associated With Outcomes of Care for Adults With Chronic Conditions? Journal of Ambulatory Care Management.30 (1); 21-29.
  • De Smet, Peter and Maaike (2004). Repeat Prescribing: Scale, Problems And Quality Management In Ambulatory Care Patients. Drugs.64(16);1779-1800.
  • Donald M. Steinwachs (1979). Measuring Provider Continuity in Ambulatory Care: An Assessment of Alternative Approaches. Medical Care 17(6):551-565.
  • GregPauly and MichaelJellinek (2005). Planning a Large Ambulatory Care Center at an Academic Medical Center. Economic, Political, and Cultural Issues.Journal of Ambulatory Care Management.28 (2); 182-193.
  • JohnH.Wasson (2008). Who Is In Charge? Even Affluent Patients Suffer Consequences of Fragmented Care. Journal of Ambulatory Care Management.31 (1); 35-36.
  • JohnH.Wasson and ReginaBenjamin (2006). Postscript: Health Disparity and Collaborative Care. Journal of Ambulatory Care Management.29 (3); 233-234.
  • JohnH.Wasson, TimAhles, DebbieJohnson, AndreaKabcenell, AnnLewis and MaggieM.Godfrey(2006). Resource Planning for Patient-centered, Collaborative Care. Journal of Ambulatory Care Management.29 (3); 207-214.
  • JohnH.Wasson, DeborahJ.Johnson, ReginaBenjamin, JillPhillips andToddA.MacKenzie (2006). Patients Report Positive Impacts of Collaborative Care. Journal of Ambulatory Care Management.29 (3); 199-206.
  • Keating NL, Green DC, Kao AC, Gazmararian JA, Wu VY, Cleary PD (2002). How Are Patients' Specific Ambulatory Care Experiences Related To Trust, Satisfaction And Considering Changing Physicians? J Gen Intern Med. 17(1):29-39.
  • KevinFiscella and PeterShin (2005). The Inverse Care Law: Implications for Healthcare of Vulnerable Populations. Journal of Ambulatory Care Management.28 (4); 304-312.
  • L.GordonMoore and JohnH.Wasson (2006). An Introduction to Technology for Patient-centered, Collaborative Care. Journal of Ambulatory Care Management.29 (3); 195-198.
  • L.GordonMoore, JohnH.Wasson, DeborahJ.Johnson and JudithZettek (2006). The Emergence of Ideal Micro Practices for Patient-centered, Collaborative Care. Journal of Ambulatory Care Management.29 (3); 215-221.
  • Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B(2004). Substitution of Doctors by Nurses in Primary Care. Cochrane Database of Systematic Reviews. Issue 4.
  • Loftus, Linda Ann, Weston and Val (2001). The Development of Nurse-Led Clinics in Cancer Care. Journal of Clinical Nursing 10(2):215-220.
  • Margie Rauch Goulding (2004). Inappropriate Medication Prescribing for Elderly Ambulatory Care Patients. Arch Intern Med.164:305-312.
  • Mary W. Carter (2003). Factors Associated with Ambulatory Care Sensitive Hospitalizations among Nursing Home Residents. Journal of Aging and Health 15(2):295-331.
  • R. Heather Palmer, Thomas A. Louis, Lee-Nah Hsu, Harriet F. Peterson, Janet K. Rothrock, Rose Strain, Mark S. Thompson and Elizabeth A. Wright(1985). Randomized Controlled Trial of Quality Assurance in Sixteen Ambulatory Care Practices. Lippincott Williams & Wilkins.
  • R. S. Morrison, E. Olson, K. R. Mertz and D. E. Meier (1995). The Inaccessibility of Advance Directives on Transfer from Ambulatory to Acute Care Settings. JAMA. 274(6).
  • S Shea, W DuMouchel and L Bahamonde (1996).A Meta-Analysis Of 16 Randomized Controlled Trials To Evaluate Computer- Based Clinical Reminder Systems For Preventive Care In The Ambulatory Setting. Journal of the American Medical Informatics Association 3; 399-409.
  • Terhilda Garrido Laura Jamieson Yvonne Zhou Andrew Wiesenthal and Louise Liang (2005).Effect of Electronic Health Records in Ambulatory Care: Retrospective, Serial, Cross Sectional Study. BMJ330; 581.
  • TerryWahls (2007). Diagnostic Errors and Abnormal Diagnostic Tests Lost to Follow-Up: A Source of Needless Waste and Delay to Treatment. Journal of Ambulatory Care Management.30 (4); 338-343.
  • ThomasD.Denberg (2008). Improving Patient Care through Health-Promotion Outreach. Journal of Ambulatory Care Management.31 (1); 76-87.
  • V A Ancona-Berk and T C Chalmers (1986). An Analysis of the Costs of Ambulatory and Inpatient Care.American Journal of Public Health. 76(9): 1102-1104.
  • ValerieE.Stone, JoelS.Weissman and PaulD.Cleary (1995).Satisfaction with Ambulatory Care Of Persons with AIDS. Journal of General Internal Medicine.10(5); 239-245.

Copyright 2008- American Society of Registered Nurses (ASRN.ORG)-All Rights Reserved


 
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Articles in this issue:

Masthead

  • Masthead

    Editor-in Chief:
    Kirsten Nicole

    Editorial Staff:
    Kirsten Nicole
    Stan Kenyon
    Robyn Bowman
    Kimberly McNabb
    Lisa Gordon
    Stephanie Robinson

    Contributors:
    Kirsten Nicole
    Stan Kenyon
    Liz Di Bernardo
    Cris Lobato
    Elisa Howard
    Susan Cramer

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