Nurses are being asked to do more. Hasn’t that always been the case? Now, more than ever, we expect to see mission creep.
Each level in the health services delivery continuum will see services driven down to the next lower level. Physician assistants and nurse practitioners are routinely providing direct medical care that has been the exclusive domain of physicians. Nurses, nurse educators, and nurse advocates are increasingly spending time with patients and their families to develop a better understanding of the environmental effects on their behavior.
TPCS nurses are trained as Behavior Transition (BeTr™) Coaches to determine how our behavior based skills can be extended to patients and their families. We are fully aware that post discharge returns to hospitals is having an impact on both costs and morbidity to the patient. Patients are being discharged sicker and quicker than ever before and greater demands are being placed on family members to replace hospital bed days with home bed days. Teach Back and Motivational Interviews are a great start but research has consistently shown that information “learned” headed out the door is often forgotten before the patient is returned to their driveway. With “quality care” penalties looming for readmissions within 30 days changes must be made to improve adherence.
TPCS nurses administer the Medication Adherence Assessment Scale (MAAS) and share the results with the attending provider and the home health team. The MAAS was specifically designed to help identify patients who are most at risk for non-adherence after discharge. TPCS Home Health Nurses can follow up and work with patients and their families to identify at-risk behaviors and develop behavior intervention plans to improve adherence.
For more information about our applied research please contact Dr. Robert Wright at (321) 439-5949.