April 3, 2012 (Chicago, Illinois) — Editor's Note: The American College of Cardiology (ACC) 61st Annual Scientific Session (ACC12) featured a joint symposium on ways that healthcare providers can use a team-based approach to improve patient outcomes.
The symposium was the first time the ACC has collaborated with a nursing organization at its annual meeting. Members of the Preventive Cardiovascular Nurses Association (PCNA) and the ACC spoke at the symposium about the role of patient-centered care in the prevention of cardiovascular disease, how to implement a team-based approach to patient care, patient education, and strategies for improving patient adherence to complex treatment regimens.
Suzanne Hughes, RN, MSN, FAHA, FPCNA, clinical education project director for the PCNA, spoke with Medscape Medical News about the topics covered at the joint symposium and about ways the PCNA is working with the ACC to improve patient outcomes.
Medscape: Was the symposium well-attended?
Ms. Hughes: We had a very nice crowd of nurses as well as physicians. This was the first time that the ACC joined with a nursing organization to do this.
Medscape: What is team-based patient care?
Ms. Hughes: We have wonderful tools that are used in preventive cardiology to reduce patients' cardiovascular risk. We have tools for cholesterol-lowering medications, blood pressure–lowering medications, and medications and therapies to help people quit smoking. We know what kind of diet recommendations work. We know that a lot of the medications to reduce the risk of restenosis after balloon angioplasty and stents are very effective, but there's a disconnect in making sure that they're used uniformly as desired.
We know that cardiac rehab saves lives and prevents heart attacks, but unfortunately, across the country, a pitifully small percentage of patients are actually referred to cardiac rehab, and a smaller number actually have their cholesterol level treated to goal. We have all these tools, and we're trying to figure out, as a healthcare system, how we use them more efficiently. We know that's going to take the team efforts of physicians, and nurses, and nurse practitioners, all of whom have an increasingly short amount of time with patients in their busy clinics.
[Speakers] talked specifically about team-based care, and about using different tools right at the point of care — checklists and things to make sure patients are getting all of what they need, and all that they should.
Cindy Lamendola [MSN, ANP-BC, FAHA, FPCNA] talked about getting patients to persist long-term with these therapies that we give them. It's a tall order because we give patients meds to lower their cholesterol or their blood pressure, and they're not drugs that make them feel better. It's hard enough for a patient to remember to take a whole antibiotic prescription or take their arthritis medicine as ordered. Think about how hard it is if you're on a medication for your whole life and it doesn't really make you feel any better. How do we get patients to stick to that?
One of the things that I talked about in my talk about patient-centered care is how we work with patients to get their buy-in. What we're trying to get away from is a really paternalistic approach where we talk at patients and tell them what they shouldn't do, what they need to do. We're trying to get from patients what's important to them.
So if we have a 75-year-old woman and we're telling her that if she takes this medicine she's going to live longer, that may not mean a lot to her. She may be more concerned with her quality of life than her length of life.
If you tell someone that by taking this medicine, they're going to live long enough to dance at their grandchildren's weddings, or that they're going to be able to go bowling again, or go on bus trips with their church group, or do something that they really want to do, that's really important. We're trying to get into this whole area of shared decision-making with patients, and to do that, we have to realize that communication is a 2-way street. We have to elicit from patients what's important to them.
It might be important to me that their [low-density lipoprotein] cholesterol is 70, but it's probably not too important to them.
We have to find out what their currency is, so we can capitalize on that to reach some shared goals. It's almost like strategic planning for one's own personal healthcare.
Medscape: What are some ways to implement a team-based approach?
Ms. Hughes: I think what we really want to do in healthcare nowadays, in the name of not only serving our patients, but also in the name of maintaining cost, is to have all healthcare providers work to the limit of their license.
If there are things in a cardiology clinic that a nurse practitioner could be doing to support or assist the physician, or to spend more time educating patients, then that's who should be doing it. If there are things that even the receptionist in your office can do to make sure that patients are getting the testing they need and so on, then that's who should be doing that. We really need to look at integrating a full team approach in the clinic.
We also need to remember that the electronic health record, or the computer system, is part of that team, and in many cases now, people are using electronic health record systems that can actually be leveraged to send patient reminders, and keep track of when things are due for patients. We really need to roll the whole team into it, and find who can best do the task, because there's plenty of work for everyone.
Medscape: What has been the response of physicians to this approach?
Ms. Hughes: I think that once the physician has the experience of working with a very knowledgeable and enthusiastic nursing professional, they are absolutely believers in that concept. We know that in many settings, for instance, patients have cholesterol disorders, or diabetes, or hypertension, and nurses are really the point people for disease management in those office settings.
It's really a great combination if the physician is working with the patient, and then from their office encounter, has the patient follow up with the nurse for more intensive education, and also, follow-up. A real core strength of nurses is making sure patients and their families are well-educated and understand everything they need to know. So many patients now have to do self-care at home that we really do need to leverage the skills of nursing to make that happen.
Medscape: What are some techniques for helping patients adhere to complex regimens?
Ms. Hughes: It's really interesting; when we think about adherence to therapy, we used to call it 'compliance,' although that sounds like we're really policing patients. We want to convey the idea of a little more of a partnership.
Adherence to therapy is a very complex thing. Many of us think adherence or nonadherence means that you give a patient a prescription for a cholesterol-lowering drug, they go and get it filled, they take it for a few weeks, and then they decide they don't want to take it anymore. But it's really much more involved than that.
There's one thing called primary nonadherence, where people are given a prescription, and they quite simply never get it filled. Because maybe they didn't even agree on the need for it, or they didn't have a trusting relationship with their provider. The way we get around that sort of nonadherence is different, and might be patient education.
Sometimes elderly patients don't take their medicine because they forget, or because they didn't understand what they were supposed to do. Sometimes patients don't adhere to therapies because they're depressed. Depression impacts their ability to remember their therapies, and sometimes they really don't even care. When people are depressed they tend to overeat, don't exercise as much, or maybe rely on cigarettes for stress reduction. We really need to look at the reasons for nonadherence — and there are many — before we start tackling patients with what therapies are going to make a difference.
Medscape: What does patient-centeredness mean in terms of prevention?
Ms. Hughes: When you think about it, patient-centeredness means a couple of different things. It means that we're forging a partnership with patients, that we're showing respect for their wants, needs, and preferences, and that we're giving them the education and support that they need to participate in their own care.
When you think about the things that we ask patients to do to lower their risk of a heart attack, or a second heart attack, a lot of them are things that are very personal, and have to do with their lifestyle. It may have to do with their eating habits, how much they're moving around, and so on. So it's really important that I don't barge in and tell a patient that they need to eat fewer fancy cheeses, or put a lid on some of their restaurant eating, or if they're in a lower socioeconomic group, and if that isn't something that they do anyway.
It means trying to meet patients where they are now, and to find out what's important to them, what their lifestyle is, and what they'd be willing to negotiate on to make those changes.
Likewise, if we have a patient who's addicted to nicotine or tobacco, and we want them to quit smoking, we need to work with them on selecting a therapy that they're going to buy in to. Would they be interested in a nicotine patch, or nicotine replacement? Would they be interested in an oral medication, or are they somebody who's going to be a candidate for some group behavior change type of strategy? You've got to meet people where they are.
We know that older groups of patients, maybe 80-plus, might be a little less able to say what they want and need, but we know that the boomers, who have now started reaching retirement age, are a consumerist group, and they're definitely going to have a desire to say how they want things to be, and how they want their healthcare to be delivered.
Medscape: Which sessions at ACC12 are of particular interest to nurses, and why?
Ms. Hughes: It's a fallacy to think that physicians need one education content and nurses need another. We're all taking care of the same patients, and we have interest in the same kinds of topics. Nurses are interested in new therapies that are on the horizon that we know might reduce the risk of heart disease. More and more nurses are really interested in the practical things that can really help them get results with their patients. I think there's more and more interest by most nurses and physicians in some of the how-to sessions, like how to work with patients using techniques like motivational interviewing, how to really get results working with patients on lifestyle change.
We also know that techniques for educating patients are really important now. There are new tools coming out with Web-based patient education. Hospitals are increasingly under the gun to make sure that we educate patients with print materials that are clear and understandable. Nurses are really interested in hearing about that, and looking at what's available to try to extend that clinical encounter in the office-based setting with additional tools to help support that encounter.
Medscape: Is PCNA planning to collaborate with ACC on anything else?
Ms. Hughes: We have a history of a wonderful, collaborative relationship. We have a formal liaison relationship with the American College of Cardiology, and on many of the College's projects, they have come to us for insight on educating patients. We've been able to make sure that the ACC members are aware of all of our patient education tools.
Likewise, we've produced a lot of very well-respected print materials for healthcare practitioners. We're known for our pocket guide on cardiovascular risk reduction, a very dense but pocket-sized guide that nurses and physicians have in their pocket at the clinic and can refer to in working with patients.
We have the latest guidelines on obesity management, blood pressure management, diabetes, and cholesterol management, how to help patients with smoking cessation, and we've been able to get those tools that we've created into the hands of practicing cardiologists across the country.
Sometime, and we think within this calendar year, we're going to have new guidelines for professionals on blood pressure, so there will be new JNC 8 guidelines [Eighth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure]. There will be new guidelines for the management of cholesterol in adults, and new guidelines for obesity. Groups are working very hard on these right now. They've been anticipated for quite some time.
PCNA is already working to redo their pocket guide to be ready to support professionals when the new guidelines are published and released.
Medscape: That sounds very exciting.
Ms. Hughes: It's a lot of work, but it's very exciting. There's nothing we'd rather be doing.
Ms. Hughes has disclosed no relevant financial relationships.
American College of Cardiology (ACC) 61st Annual Scientific Session. PCNA Symposium. Presented March 26, 2012.
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Cite this: Nurses, Physicians Hold Joint Symposium on Team-Based Care at ACC12 - Medscape - Apr 03, 2012.