AACN Synergy Model for Patient Care - American Association of ...

UsingtheAACNSynergyModelAACN Synergy Modelfor Patient CareCase Study of a CHF PatientSonya Hardin, RN, PhD, CCRN, CSLeslie Hussey, RN, PhDrole as a clinical nurse specialist(CNS)/adult nurse practitioner(ANP). The advanced practice nursewith a CNS/ANP degree can have asignificant impact on healthcare bypreventing chronic illness and promotinghealthy lifestyles and influencethe delivery, cost, and qualityof healthcare to persons withchronic illness. 2The AACN Synergy Model forPatient Care describes a frameworkfor nursing practice. The key to thismodel is the linkage of patient characteristicswith nurse competenciesto achieve optimal patient outcomes.1 The Synergy Model is readilyadaptable to the acute care or criticalcare setting when the patient is criticallyill and the intensive care nurselinks his or her own competencies tothe patient’s characteristics. However,not all acute care is conductedAuthorsSonya Hardin is an assistant professorand coordinator of the MSN/MHA programat the School of Nursing, Universityof NC at Charlotte, NC.Leslie Hussey is an associate professor atthe School of Nursing, Chair Adult HealthNursing Department, University of NC atCharlotte.To purchase reprints, contact The InnoVisionGroup, 101 Columbia, Aliso Viejo, CA 92656.Phone, (800) 809-2273 or (949) 362-2050 (ext532); fax, (949) 362-2049; e-mail,reprints@aacn.org.within the walls of the hospital setting.Today’s healthcare environmentmandates that patients with seriousdiseases live in their homes, causingthe need for acute and critical caresettings to reach out to their patientsnot only to assist them in maintaininga quality of life but also todecrease costs of hospital readmissions.This situation is especially truefor patients with chronic heart failure(CHF). In the United States, manypatients with CHF regularly visit CHFclinics that are run by advanced practicenurses; these clinics assistpatients with maintaining and oftenimproving their state of heart failure,while also proving cost-effective.The Synergy Model provides theframework for nurses to managecomplex clients experiencing acuteexasperation of their illness and towork toward reducing the trajectoryof the illness. The purpose of thisarticle is to discuss the application ofThe Synergy Model to an ambulatoryCHF clinic. We will discuss thecharacteristics of a patient whovisited a local clinic, with theadvanced practice nurse holding aBackground of CHFCHF is a major public healthproblem; it is the most commondiagnosis for people older than 65years of age who are dischargedfrom hospitals. CHF is a progressiveand chronic disease that limitspatients’ functional status andseverely lowers their quality of life.Currently, CHF is the number onediagnosis of Medicare beneficiaries,costing $10 to $30 billion annually. 3Although significant advances havebeen made in determining both thepathophysiology and therapy forCHF, there has been surprisingly littlechange in mortality rates over thepast 4 decades. 4 The 5-year mortalityrate for patients with symptomaticheart failure is almost 50%, and upto 40% of these deaths are sudden. 5CHF not only increases mortalitybut also has a dramatic effect onpatients’ functional ability and qualityof life. Nearly 1 million patientswith CHF cannot live their liveswithout some restriction on activitybecause of the signs and symptomsof heart failure. 6Data indicate that between onethird and one half of heart failurereadmissions, particularly thoseCRITICALCARENURSE Vol 23, No. 1, FEBRUARY 2003 73

UsingtheAACNSynergyModeloccurring within 90 days, are preventable.7 Factors that contribute topreventable hospitalizations areinadequate patient and caregivereducation, poor symptom control,insufficient social support, andinadequate discharge planning. 8Successful management of peoplewith CHF often includes long-termlifestyle adjustments by patients andfamilies. Lifestyle adjustments focuson modifications in diet and activities,adherence to a complex medicationregimen, and the need tomonitor symptoms. The success oflifestyle adjustments depends notonly on the person with CHF butalso on his or her social support. 8In the early stages, patients withheart failure may have minimalphysical limitations and symptoms.In later stages, ordinary daily activitiesbecome difficult, even at rest.Typically, the first key indicator oftransition from early- to late-stageCHF is hospital admission.Unfortunately, both physical andpsychosocial interventions typicallybecome aggressive only during thelate stages of heart failure, which isusually too late to significantly affectmortality. This delay of interventionis partly due to the fact that patientsin early stages of CHF do not seekmedical treatment until their conditionrequires hospitalization.Because of the incidence and costof CHF, many organizations havedeveloped innovative specializedclinics managed by advance practicenurses to provide intensive outpatientambulatory care for the CHFpopulation. These clinics wereformed to enhance the appropriateuse of therapies and to bring aboutdesired health maintenance anddecreased rehospitalization. Suchclinics typically provide primarycare, counseling, education, andintensive follow-up. Numerous studiesshow that improved outcomescan be obtained through such nursemanagedclinics. 9,10Most CHF clinics operate withinthe outpatient setting, near a hospital.Criteria for admission to suchclinics include but are not limited to:ejection fraction of 0.40 or less, NewYork Heart Association class II to IVas determined by a physician, readmissionto the hospital 1 or moretimes in the past year, and a historyof CHF. These clinics are managedby advanced practice nurses who areeither CNSs or ANPs and who arethe primary providers of care in consultationwith the medical directorof the clinic.Patients attend the clinic fromtwice a week to once a month; theyare reassessed at each visit and evaluatedfor continued therapies andeducation. Advanced practice nursesare excellent candidates to managethis complex population. Theirinterventions can result in adecrease in the readmission rate andan improved quality of life. Throughtheir education, nurses learn toapproach a patient holistically, integratingmany aspects of care. Thisintegration is key to the success ofpatient management and leads topositive outcomes. Readmission ofCHF, along with resultant costs ofhospitalization is decreased. Patientinvolvement in treatment demandsthe skill, expertise, and education ofthe nurse, not only in the initialassessment, but also in the ongoingcoaching process. Advanced practicenurses today, and increasingly in thefuture, will become primary careproviders for this important groupof patients. Nurse-based models ofcare must be tested to determinetheir effectiveness and generalizabilityto recipients of healthcare.Sophie’s StorySophie, an 82-year-old AfricanAmerican woman, had New YorkHeart Association class III CHF. Shewas a widow, lived alone, and hersole financial support was SocialSecurity. She had been hospitalizedtwice in the past 18 months for exacerbationsof CHF. She had had astroke, which had left her dependenton a cane for ambulation. She hadhypertension, osteoporosis, atrial fibrillation,and diabetes mellitus type2, which was controlled with diet;also, she took oral hypoglycemics.Sophie had a daughter who caredabout her but was unable to provideany supplemental financial support.Sophie took the following medications:an angiotensin-convertingenzyme inhibitor, digoxin, potassium,fosinopril sodium, coumadin,and furosemide. Her medicationscost her approximately $350 permonth. Because she did not have anyother insurance except Medicare,Sophie payed for medications herself.She did not drive but used publictransportation to travel to the clinicand for other trips such as going tothe grocery store and church. Sophiecame to the CHF clinic every 2 weeks.On the morning of one visit,Sophie was complaining of slightshortness of breath. She had gained3 lb since her last visit. Her bloodpressure was elevated to 176/94 mmHg—it was normally around 130/80mm Hg. Her pulse was 106beats/min and irregular, and shestated that her shoes did not fit soshe had to wear her slippers. Her74 CRITICALCARENURSE Vol 23, No. 1, FEBRUARY 2003

UsingtheAACNSynergyModelTable 2 The competencies needed by Sophie’s nurseClinical judgementAdvocacy and moralagencyCaring practicesFacilitation of learningCollaborationSystems thinkingResponse to diversityClinical inquiryAnalyze assessment data and make decisions based upon theneeds of the clientSupport patient in her decisions to remain independentImplement a process to ensure that resources are obtained forthe patientEnsure that Sophie understand her disease process,medications and results of choices in relation to her healthUtilize resources in the community to meet the needs of thepatientAnticipate possible strategies to ensure compliance withinterventionsRespect the clients values and beliefsQuestion the client to analyze which innovative strategieswould be most successful with the client.ConclusionThe Synergy Model is applicableto a variety of settings. Specifically,the use of the Synergy Model in anambulatory setting is an example ofthe flexibility of the model. Theadvanced practice nurse in anambulatory clinic uses the competencesdescribed in the model toensure optimal outcomes for thepatient. The Synergy Model can beapplied in numerous settings andcan guide the practice of advancedpractice nurses.The nurse had to develop, integrate,apply, and evaluate a variety ofstrategies to meet the needs of thepatient. 12 The strength of an ambulatorysetting is that protocols arein place to do follow-up phone callswith patients to ensure continuedprogress and answer questions thatcan occur after the visit. Typically, anadvanced practice nurse would usesystems thinking to develop proactivestrategies that could ensure improvedutilization of services through theCHF clinic for Sophie. These strategiescould include sample medicationsto be given during the last weekof each month or to investigate thepotential for Sophie to be involved inindigent programs sponsored bypharmaceutical companies.Lastly, the nurses must respondto the diversity presented by eachpatient. In Sophie’s situation, thenurse must respect the client’s wishesto maintain her value of independenceand pride in not accepting charity.Also, the nurse must supportSophie in her preference for foodchoices. A response to diversitymeans recognizing cultural or ethnicdifferences in the provision of care. 13All the nurse competencies withinthe Synergy Model were importantin the care of Sophie.OutcomesThe advanced practice nurse inthis situation utilized the competenciesin the model to meet the needsof the patient. Sophie was connectedwith the local Meals on Wheels program,which agreed to provide 1 hotmeal per day. In a follow-up phonecall, Sophie reported that enoughfood was delivered every day so thatshe could actually save some of it tohave with dinner. The CNS/ANPadjusted Sophie’s medicationregime, followed up with phone callsto her home on day 3 and 5 to ensurecompliance and to answer questions.A decision was made by the patientto allow the advanced practice nurseto seek information regarding indigentprograms for several of thedrugs and to utilize drug samples atthe end of each month until a programcould be obtained for theclient. The client also acknowledgedher understanding of following aprotocol to weigh herself daily and tocall into the clinic for a weight gainof greater than 1 lb for possible fluidrestrictions and drug adjustments.References1. Curley MAQ. Patient-nurse synergy: optimizingpatients’ outcomes. Am J Crit Care.1998;7:64-72.2. UNC Charlotte Web site. Available at:http://www.uncc.edu/colleges/health/depfacstaff_frame.htm. Accessed October2002.3. Lenfent C. Cardiovascular research: an NIHperspective. Cardiovasc Surg. 1997;4:4-5.4. Ho KKL, Anderson KM, Kannel WB,Grossman W, Levy D. Survival after theonset of congestive heart failure inFramingham Heart Study Subjects.Circulation. 1993;88:107-115.5. Singh SN. CHF and arrhythmias: treatmentmodalities. J Cardiovasc Eletrophysiol.1996;89:89-97.6. Konstam M, Dracup K, Baker D, et al. HeartFailure: Evaluation and Care of Patients WithLeft-Ventricular Systolic Dysfunction. ClinicalPractice Guideline No.11. Rockville, Md:Agency for Health Care Policy andResearch; 1994. Publication No. 94-0612.7. Shah NB, Der E, Ruggerio C, Heidenreich P,Massie B. Prevention of hospitalizations forheart failure with an interactive home monitoringprogram. Am Heart J. 1998;135:373-378.8. Wehby D, Brenner PS. Perceived learningneeds of patients with heart failure. HeartLung. 1999;28:31-40.9. McAlister FA, Keo KT, Taher M, et al.Insights into the contemporary epidemiologyand outpatient management of congestiveheart failure. Am Heart J.1999;138:87-94.10. Hendrick A. Cost-effective outpatient managementof persons with heart failure. ProgCardiovasc Nurs. 2001;16(2):50-56.11. Hardin S, Hussey L. The Synergy Model inpractice: clinical inquiry. Crit Care Nurse.April 2001;21:88-91.12. Moloney-Harmon PA. The Synergy Model:contemporary practice of the clinical specialist.Crit Care Nurse. April 1999;19:101-104.13. Doble RK, Curley MAQ, Hession-Labard E,Marino BL, Shaw SM. Using the SynergyModel to link nursing care to diagnosisrelatied groups. Crit Care Nurse. June2000;20:86-92.76 CRITICALCARENURSE Vol 23, No. 1, FEBRUARY 2003