Scholarship & Research
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Item A quality improvement project to bolster psychiatric advance directive utilization in community mental health(Montana State University - Bozeman, College of Nursing, 2024) Fonner, Laira Lee; Chairperson, Graduate Committee: Lindsay Benes; This is a manuscript style paper that includes co-authored chapters.Background: This quality improvement (QI) project aimed to increase Psychiatric Advance Directive (PAD) use in a community mental health organization serving clients with severe mental illness (SMI). PAD utilization has been shown to decrease involuntary hospitalization rates and associated coercive treatments, such as forced medication and seclusion and restraint for this vulnerable patient population. Local Problem: In Montana, busy clinicians rarely offer PAD education and assistance to clients with SMI. However, studies have demonstrated increased PAD utilization followed by reduced involuntary hospitalization rates for clients receiving these services from Peer Support Specialists (PSSs). PSSs are trusted employees with SMI working in outpatient mental health facilities. Methods: This quality improvement project established a repeatable PAD implementation workflow in an outpatient mental health care organization where PSSs were trained to facilitate PAD support events. Interventions: Interventions included hosting three online training workshops for PSSs followed by peer- facilitated events to offer client education and assistance in PAD completion. Event attendees were asked to complete event feedback surveys. Results: All invited PSSs attended one of the three online training workshops (n=X). X clients attended peer-facilitated events of X invited. Only two clients completed documents during the peer- facilitated events. Five clients started documents and wished to complete them later. None of the attendees completed event feedback surveys. Conclusions: The project successfully increased PAD awareness and utilization for PSSs and clients with SMI. The project team successfully established a repeatable workflow to bolster PAD use and generated organizational enthusiasm to continue utilization efforts.Item Improving advance directive conversations in a primary care clinic: a quality improvement intervention(Montana State University - Bozeman, College of Nursing, 2022) Hong, Mikyong; Chairperson, Graduate Committee: Sandra Benavides-VaelloBackground: Leading American health organizations have emphasized the necessity of promoting end-of-life conversations in health care settings. Yet the rates of these conversations remain woefully low across all settings, including primary care. Advance directives (AD) are documents that relay the degree of medical care desired by a patient. Thus, ADs are a practical and appropriate approach that can be used by primary care providers for initiating end-of-life conversations with their patients. Purpose and Methods: The purpose of this DNP project was to increase the rates of advance directive (AD) conversations between providers and their patients in a primary care setting. The project used provider training instruments that were developed within a scientific framework. These instruments included: 1) a tutorial on the appropriate use of AD related CPT codes, 2) a documentation guide for advance care planning, 3) a conversation guide for discussing ADs with patients, and 4) education on the use of the (AD) form. These instruments were delivered over eight weekly video tutorials and in-person question and answer sessions. Results: The rates of end-of-life conversation at the clinic, as reflected in advance care planning (ACP) documentation and scanned AD forms in EMRs, increased from 12% of patients to 35%. The project also improved patient care and generated revenue for the organization through the utilization of Current Procedural Terminology (CPT) codes related to advanced directive conversations.Item Implementing advance directive screening and education in the primary care setting(Montana State University - Bozeman, College of Nursing, 2021) Nordlund, Sarah Lou; Chairperson, Graduate Committee: Yoshiko Yamashita Colclough and Polly Petersen (co-chair)Advance care planning is a topic that has become increasing important due to medical technology advancement and the growing population of elderly Americans. Although advance care planning has been proven to positively impact patient satisfaction and quality of care, education and advance directive formulation does not occur as often as it should. The primary aim of this project was to increase the number of completed advance directives in patient medical records by 10% at a small rural Critical Access Hospital. The intervention implemented was screening patients age 65 and older for the presence of an advance directive during the clinic intake process. Patients that reported having a completed advance directive were asked to provide the site a copy and patients that reported not having an advance directive were provided an educational packet. A total of 5 patients presented to the clinic during the 6-week data collection period that were age 65 and older. Of these patients, 40% (n=2) reported having a completed advance directive, and both returned a copy. There were 40% (n=2) that reported not having a completed advance directive and did not return a completed copy. One patient did not get screened by mistake. The site is considering adjusting the screening process to be the responsibility of the clinician instead of the receptionist. A social media post was created on the site's Facebook page requesting individuals that had a completed advance directive to provide the facility a copy resulting in three additional individuals (n=3) bringing in completed directives. The goal to increase completed advance directives in patient medical records was met. A secondary aim of this project was to have facility clinicians complete an advance care planning education course from the education platform Relias, promoting their comfort to have the conversation with the patients. Facility clinicians have not yet completed the education, but the course was added to the facility's annual requirements. Currently 16 out of 36 of the non-clinician employees have completed this education course. The interventions adopted for this DNP QI project brought awareness to important topic of advance care planning and increased advance directive formulation.Item The nurse practitioner's perspective of the physician orders for life-sustaining treatment (POLST) form(Montana State University - Bozeman, College of Nursing, 2020) McAllister, Sarah Elizabeth; Chairperson, Graduate Committee: Stacy StellflugThe assessment, documentation, and implementation of a Physician Orders for Life-Sustaining Treatment (POLST) form are important for end-of-life care. As primary care providers, nurse practitioners have an important role in advanced-care planning, including the completion of POLST forms (Hayes et al., 2017). The purpose of this project was to better understand the self-reported practices and opinions of nurse practitioners as they assist patients in completing the form. The project was a partial needs assessment to inform later quality improvement (QI) work and used a survey design to assess and gain better understanding of the practices and opinions of nurse practitioners with the POLST form. Questions 1, 4, 6, and 8 were 'select all that apply' and Questions 2, 5, 7, and 9 required a single response. A total of 126 surveys were sent out with a response rate of 39.6%. Overall, nurse practitioners in Billings, Montana, were familiar with the POLST form (n=45, 90%). Half (n=28, 50%) of the nurse practitioners surveyed used the POLST form in their clinical practice despite having barriers to its completion such as it being time consuming (n=18, 25.7%). Over half (n=45, 60.0%) of the nurse practitioners surveyed believed that the most appropriate time to complete the POLST form was after a provider (any provider) discusses goals of care and medical treatments with the patient and/or family. Although some nurse practitioner respondents had no concerns with completing the POLST form (n=12, 21.1%), 21 of the respondents (n=21, 36.8%) reported issues regarding the understandability of the form for patients and/or families. Survey results showed familiarity of the POLST form is not a barrier to its completion in Billings, Montana, but 25.7% of the respondents believed the time it takes to complete the form was a barrier to completing it with patients and/or families. Nurse practitioners could include extra time in appointments or use annual wellness visits to discuss goals of care with patients and/or families. Future effort could also focus on reducing the amount of time nurse practitioners spend filling out a POLST form accurately and completely with their patients and/or families.