Dr. Jacelon is Associate Professor, School of Nursing, University of Massachusetts, Amherst, and Scholar in Residence, Jewish Geriatric Services, Amherst, Ms. Furman is Director of Education, and Ms. Rea is Director of Nurses, Julian J. Leavitt Jewish Nursing Home, Jewish Geriatric Services, and Ms. Macdonald is Director of Professional Practice, and Ms. Donoghue is Chief Nursing Officer, Jewish Geriatric Services, Longmeadow, Massachusetts.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Cynthia S. Jacelon, PhD, RN, CRRN, Associate Professor, School of Nursing, University of Massachusetts, Amherst, 126 Skinner Hall, 651 North Pleasant Street, Amherst, MA 01003; e-mail: email@example.com.
Only 4% of older adults live in nursing homes at any given time, although many more experience nursing home life at some point (Federal Interagency Forum on Aging-Related Statistics, 2010). In addition, the growing number of older adults, greater longevity and chronic disease prevalence, and changes in the American family are increasing the demand for supportive living environments. These environments must be designed to promote residents’ independence and ability to self-manage chronic health problems. A professional practice model is “a schematic description of a…sys-tem that depicts how nurses practice, collaborate, communicate, and develop professionally to provide the highest quality care for those served by the organization” (American Nurses Credentialing Center, 2008, p. 24). Such a model for postacute care can guide care to help residents realize their full potential.
Health care in long-term care settings has typically been based on a hospital, medical model designed to manage acute illness. At Jewish Geriatric Services, Inc. (JGS) in Long-meadow, Massachusetts, we determined that the acute, medical model was inconsistent with our mission, which states, in part, that JGS is dedicated to “improving the physical, spiritual and emotional health of individuals and families by providing a comprehensive range of health, education, and social services guided by Jewish traditions and values” (JGS, 2006, Our Mission Statement, para. 1). We wanted a nursing professional practice model that reflected the philosophy and regulations of postacute care, was congruent with the metaparadigm of nursing (client, nurse/health care system, health, environment) (Fawcett, 1995), focused on the relationship between the nurse and resident, was appropriate for the populations for whom we care, and supportive of professional nursing practice, including a framework for research. We wanted a model that was applicable in residential facilities and that could be used for organizing the entire system, not only the nursing component. The process used to develop a middle range theory of nursing practice, the structure of the theory, and early examples of outcomes are presented below.
The clinical leaders from JGS searched the health care literature for a practice model that would meet our goals. The Chronic Care Model (CCM; Improving Chronic Illness Care [ICIC], n.d.) was identified as having potential. Although the CCM has been applied to outpatient nursing settings (Barr et al., 2003; Boville et al., 2007; Fiandt, 2006; Fulton, Penney, & Traft, 2001; Hennessey & Suter, 2009; McEvoy & Barnes, 2007; Phillips, Davidson, Jackson, & Kristjanson, 2007; Stock, Reece, & Cesario, 2004), it has not been adapted to residential care. By adapting the CCM (Wagner, 1998), we developed a middle range nursing theory: the Jewish Geriatric Services-Chronic Care Model (JGS-CCM) to guide nursing practice in postacute care (Figure).
Figure. Jewish Geriatric Services-Chronic Care Model.
Organizing a postacute care system based on a theoretical model of care delivery that incorporates the community, the older adult, and the care providers as partners in care delivery can improve resident satisfaction and quality of life. It can also improve communication and coordination within the health care system and among the system, other care providers, and the community at large. We are using the theory across the system, including nursing home care, home health and hospice care, assisted living, and adult day health. Our implementation of the JGS-CCM can serve as a model to improve care in other residential settings.
The CCM was developed for outpatient physician practices (Wagner, 1998). The usual way of providing care for individuals with acute illnesses was inadequate for people with chronic diseases such as diabetes, heart problems, and high blood pressure. If care delivery were redesigned to meet the needs of these individuals, they would be healthier, and health care costs would be reduced because the patients would have fewer emergencies. The model has six components: (a) the community, (b) the health care system composed of (c) self-management support, (d) delivery system design, (e) decision support, and (f) clinical information system (ICIC, n.d.). “The six CCM elements work in concert, providing both patients and their professional caregivers with the information, skills, incentives, and resources essential for optimal management of chronic disease” (Glasgow, Orleans, Wagner, Curry, & Solberg, 2001, p. 602).
The goal of the model is to have a prepared, proactive practice team interacting with an informed active patient to improve functional and clinical outcomes (ICIC, n.d.). The patient is conceptualized as using community and health care system resources to make informed decisions about his or her health practices and disease management. The health care system is designed to support the community-based internist and provide support for regular management of chronic disease, thereby reducing the frequency of acute exacerbations. The computerized clinical information system would not only be a repository of information but could facilitate management by reminding the patient and physician of the need for various assessments (Bodenheimer, 2003).
Adapting the CCM to Nursing in Postacute Care
Although the CCM has been effective in transforming physician care of individuals with chronic diseases (Coleman, Austin, Brach, & Wagner, 2009; Sperl-Hillen et al., 2004), we wanted to create a professional practice framework for a residential, long-term care system in which the individual was a frail older adult with chronic health problems and the primary care provider was a nurse. We began the adaptation of the CCM to nursing practice by reconceptualizing each component for our practice setting. After long discussion, we developed a figure that we could use to explain the adaptation of the JGS-CCM (Figure).
In the JGS-CCM, we redefined the six components of the CCM (Wagner, 1998) to create a model for high-quality chronic disease care, including: community resources, self-management support, delivery system design, decision support, and clinical information system. These five components encircle the sixth: the nurse with the individual and family. We added definitions of the resident and the nurse. The goal of the JGS-CCM is that the resident, with or without a family member, together with a proactive, prepared nursing team, is involved in his or her plan of care.
We conceptualized the community as the environment. In the Wagner CCM, the goal of this component was to mobilize community resources to meet needs of patients and to encourage patients to participate in community-based programs to support their self-management (ICIC, n.d.). In the JGS-CCM, the community includes an internal component—the community within the postacute care system—and the external component—the community in which the system is embedded. The internal community is the residential environment, including strong spiritual support, as well as the usual long-term care services. Residents are encouraged to engage with the community within the system.
The postacute care system is embedded in the larger community. The external community is connected with our residents through volunteer activities, educational programs, and trips to area events. A reciprocal relationship exists between the internal JGS community and the external community. There are six aspects of the external community: volunteers, families and friends, schools, government and social agencies, religious institutions, and other health care services.
The person in the JGS-CCM is a holistic individual, living in our facilities, who is actively engaged in managing his or her health and daily life to the best of his or her ability. This individual has chronic health problems and requires coaching and assistance to meet his or her health needs. The resident also has spiritual, social, and activity needs. This is why the concept of the internal community is so important to our residents. Our description of the person is informed by Jacelon’s (2010) research on older adults living with chronic health problems, and Thorne and Paterson’s (1998) work on theories of chronic illness. Across the system, our residents are encouraged and supported at their maximum level of self-management and independence.
Self-management in the JGS-CCM represents health in the metaparadigm of nursing. The health care system is focused on empowering and supporting patients’ self-management of chronic disease (ICIC, n.d.). Self-management is defined in the nursing literature as the decisions and activities individuals make on a daily basis to manage their chronic health problems (Grey, Knafl, & McCorkle, 2006) and as “creating a sense of order” in their lives (Kralik, Koch, Price, & Howard, 2004, p. 259). At JGS, we have defined self-management as residents taking an active part in the decisions regarding their everyday lives. Residents must learn about their health problems and share the responsibility for managing those problems.
The goal of self-management is for the JGS residents to improve or maintain function and independence. The relationship between the resident and the nurse is the center of our model. It is critical in a long-term care community to capture self-management moments; they are measured differently for every resident/participant, depending on level of function. For residents in our Alzheimer’s disease units, self-management could be pointing to the shirt the resident wants to wear. For other residents, it may mean making decisions about medications. The outcomes of successful self-management include improved physical, spiritual, and emotional health, leading to better disease management, maximum function, enhanced dignity, sense of control over one’s life, and quality of life. Although promoting resident independence is not new, conceptualizing it as self-management in a middle range theory is unique.
The nurse is at the center of the JGS-CCM. In this role as direct care provider, the nurse practices holistic care encompassing the unique characteristics of individuals. Consistent with newer nursing theories of chronic illness (Huffman, 2007; Thorne & Paterson, 1998), our nurses partner with residents, emphasizing their strengths and promoting self-management. Nurses are responsible for providing nursing care, health maintenance, teaching, counseling, planning, and restoration for optimal functioning and comfort of those they serve (Massachusetts Nurse Practice Act, n.d.). Parker (2006) noted that the everyday experience of nurses is a major source of nursing practice theory. Our philosophy of nursing was derived through discussion with our nurses about their practice and states:
Nurses serve as advocates for individuals and their families by becoming partners in the development and adaptation of a plan of care that appreciates the individual’s ability to participate in self-management throughout the continuum of care. Nurses respond to the changes within society and health care by examining current best nursing practice through continuing nursing education, research, research utilization, and quality improvement processes with the objective of delivering excellent nursing care. Nurses are empowered to participate in all aspects of professional decision-making and care delivery
Health Care Delivery System
In the CCM, the health care system is described as a health care organization that is dedicated to creating an environment that promotes safe, high-quality care (ICIC, n.d.). In our theory, the health care system is conceptualized as the postacute care system that is involved in all aspects of residents’ lives. JGS is a not-for-profit organization that provides a comprehensive range of services for older adults with chronic health problems. These services include a 200-bed skilled nursing facility providing long-term nursing care, short-term rehabilitation, and specialized Alzheimer’s disease care and a 70-unit assisted living residence providing personal care assistance, wellness nursing/programs, and specialized Alzheimer’s disease care in an apartment-like setting. In addition, JGS includes a home health care agency and hospice, medical model adult day health care program, a community-based medical practice, subsidized independent living, and case management services.
The goal of the delivery system is to assure the delivery of effective, efficient clinical care and self-management support (ICIC, n.d.). The CCM is predicated on planned reassessments. In long-term care, we already had processes for regular reassessment. What was needed was revision of the way in which reassessments were envisioned and enacted. The CCM delivery system includes team function, transformational leadership, and realistic and meaningful opportunities for patients to participate in their health management (Sperl-Hillen et al., 2004).
In the JGS-CCM, the delivery system is a component of the nurse/health care system within the metaparadigm of nursing. The delivery system is the actual way in which care is delivered to provide residents the maximum opportunity to participate in their health management. This portion of the model includes nursing practice models, scheduling of staff, care routines, and the organizational structure to ensure nurses are present to engage with residents. The delivery system used by each entity within JGS is different. The delivery system in the Jewish Nursing Home is based on team nursing; at Spectrum Home Health and Hospice it is primary nursing; and at Ruth’s House it is wellness/prevention nursing.
The CCM component of decision support promotes health care that is consistent with professional standards of care, scientific evidence, and patient preferences (ICIC, n.d.). We have conceptualized decision support as another aspect of the nurse/health care system. The goal is to embed evidence-based guidelines into everyday nursing care and provide specialist expertise when needed. In the JGS-CCM, decision support is provided by the leadership of the agency, as well as the cadre of nurse practitioners, clinical nurse specialists, pharmacists, and physicians who support the nurse and resident in that relationship.
Clinical Information System
The clinical information system is the final supporting component of the nurse/health care system. According to ICIC (n.d.), the clinical information system should be organized to facilitate efficient and effective care. We have conceptualized the clinical information system as all communication among members of the multidisciplinary health care team, the resident, and the community in relation to health issues. Communication occurs among team members and residents (and family) informally during daily interactions, as well as formally during care plan meetings and other meetings. Communication between the nurse and the internal community happens informally through daily interactions and formally through the daily meetings that occur in each JGS unit. Communication with the external community is realized through interactions the nurses have with the professional community at large.
The clinical information system at JGS is not yet computerized. However, the documentation system has been redesigned to support the reconceptualization of care to include concepts of the JGS-CCM, including self-management and a focus on function. In addition, as the agency moves toward using electronic medical records, staff are developing evidence-based protocols for care, as well as easily accessible computer resources to support nurses’ practice.
To implement the JGS-CCM, we applied a model of change that would help the long-term care system evolve. Lewin’s Change Theory suggests three stages of change: unfreezing, moving, and refreezing (Lehman, 2008; Roussel, Swansburg, & Swansburg, 2006). Unfreezing determines staffs’ readiness for change, moving involves implementation of change, and refreezing maintains change.
The unfreezing stage includes dissatisfaction with the present combined with motivation to change. JGS did not have a defined nursing practice model but considered such a theory necessary for the evolution of nursing practice and nursing excellence. During this phase of change, barriers to the desired change were identified and addressed. The first barrier was general system resistance to change. The nursing leadership team developed a plan for implementation that included engagement and education of staff.
Engagement of Staff. The nursing leadership began talking with staff about the rationale for a nursing practice model in general and the JGS-CCM in particular. The JGS-CCM was introduced to management within the facility so as to develop an understanding of the model and the process of application. Managers were then able to disseminate information about the theory, act as a resource to answer questions, and facilitate overall implementation of the model. Subsequently, all staff were introduced to the JGS-CCM. All committees of JGS integrated appropriate aspects of the JGS-CCM into their purpose, functions, and activities.
Education. Group presentations of the how, what, when, where, and why of the JGS-CCM were held with nursing staff at inservice sessions across the system. A schematic that represented the JGS-CCM (Figure) was used to facilitate conceptual understanding, and this schematic was further adapted based on staff feedback. A calendar was disseminated, which focused on one concept of the model each month and included examples of how the JGS-CCM was implemented on a daily basis. Monthly meetings were held with nursing staff to ensure thorough understanding of the JGS-CCM and allay anxiety related to change and theory implementation. Staff were encouraged to design bulletin boards focusing on the theory that were unique and representative of their unit. This challenge promoted creativity and was motivational.
The moving stage involved the implementation of the JGS-CCM. We revised the resident care plan, which outlines the multidisciplinary approach to care based on the individual resident’s needs. Traditionally, care plans have been problem oriented. Implementation of the JGS-CCM required a change from problem-focused plans to plans focused on self-management and functional maintenance. Care plan language was adapted to reflect this change. In addition, nurses and members of other disciplines had to rethink how care was delivered, including how to better involve residents and families into the plan of care. This partnering philosophy was integrated through resident and family meetings on admission and quarterly thereafter.
While resident education had always been a significant component of care, tools were developed that would help the nurses with education. Access to evidence-based nursing practice methods and best-practice recommendations was facilitated through use of online resources. Committees developed educational materials consistent with the JGS-CCM and determined by nurses’ and residents’ educational needs.
During the refreezing stage, forces are at work to maintain change. Resident care plans continue to be implemented and adapted to best manage resident chronic diseases, consistent with the concepts of the JGS-CCM. Nurses, as well as residents and their families, are learning how to collaborate to improve resident outcomes based on the JGS-CCM. Nurses now understand that their practice must be evidence based rather than tradition based. A change in nursing philosophy and practice is evident; yet, new methods to better integrate the JGS-CCM continue to evolve. Outcomes of implementation of the JGS-CCM include expanding the worldview of our nurses with potential improvement of resident outcomes.
Although we are still in the change phase for some aspects of the model and in the refreezing stage for others, we do have some early outcomes. To implement the JGS-CCM, we have created a series of Councils (Practice, Quality, Community Relations, Research, Education, and Steering). The Councils complement the Resident Councils and provide a forum for shared governance with respect to resident care across the JGS system, especially as these components are integrated under the umbrella of the JGS-CCM.
Our internal community has become more responsive to resident needs. Activities to build community within the facilities abound. One example of building relationships within our internal community took place when residents from the nursing home joined with residents from our senior housing to knit shawls and lap blankets as a service project. The goods were distributed through the Community Relations Council.
Through the assessment of our internal and external community, the organization has greater awareness of how we engage with our community. We determined that we have reciprocal relationships with our external community in six areas: business and professional associations, religious communities, government and social service entities, health care agencies, schools, and families and friends (White, 2006).
We have many business relationships with the external community. JGS has relationships with suppliers, and as a not-for-profit organization, our Board of Directors is composed of volunteers. Many of these individuals are community leaders who are dedicated to promoting quality care for local older adults. Also, our staff serve on boards of many community and professional agencies.
Being a Kosher facility, we enjoy a unique relationship with other Jewish agencies. However, because our residents are diverse in their religious orientation, we have regular services from several synagogues and churches. Our Rabbi attends to the spiritual health of all of our residents and helps residents engage in meaningful spiritual activity. Other activities designed to address spiritual health include celebrating Jewish holidays; memorial services for deceased residents attended by residents, family members, and staff; and a program to provide company for residents in their last hours of life.
Our relationship with schools brings students of many ages into the agency. In addition to providing clinical experience for nursing students, we have college students from engineering, business, computer science, and many other disciplines. These students are learning clinical skills, gaining exposure to older adults and long-term care systems, and conducting research into improving the lives of older adults. We also have programs for younger students.
We have active relationships with many other health care agencies. JGS contracts with other organizations for pharmacy and laboratory services, and residents are often admitted from local hospitals, and some may need to return to hospitals from time to time. Residents may choose to keep their physician or transfer to the care of the medical director. Along with other health care agencies, we maintain relationships with government and social service agencies, such as the town, county, and state governments; regulatory bodies; senior services; and self-help organizations. Residents and staff regularly engage in service projects for the greater community, such as Alzheimer’s walks or the United Way™.
Friends and family are the sixth component of our external community. Keeping our residents connected with their community of origin is an integral part of quality of life. Family and friends visit freely. Many family members serve as volunteers throughout the system. In addition to the Resident Councils, we have Family Councils as well. We have a vital volunteer pool, many of whom live in our senior housing. Volunteers log more than 8,400 hours per year providing services such as visiting, administrative assistance, managing the gift shop and coffee shop, and providing entertainment to residents and staff. During the implementation of the JGS-CCM, we reidentified the importance of the internal and external community to our residents’ quality of life. We continue to explore ways to encourage our residents to engage with each other and with the community at large to enhance their health self-management.
It is essential to our residents’ well-being that each participates in his or her care planning process, thus assisting to manage his or her health. Creating opportunities for residents to manage their health required a new way of thinking for the staff as well as the residents. For thinking to evolve from a belief in concepts such as compliance and adherence to a framework for self-management, much discussion was required. Redesigning our documents as noted above helped this process. We determined that the one chronic health problem that every resident across the system experienced was an alteration in functional ability.
Having knowledge of care options is a critical part of helping residents self-manage their health. The Education Council has developed pamphlets for residents and family members to inform them about common health management issues, such as pain. The Education Council is also working on a pamphlet for residents, visitors, and staff to explain the JGS-CCM to facilitate participation in care. As an adjunct to our self-management program, there is a plan to create a resource/information center for resident and family use.
Delivery System Design
Since the implementation of the JGS-CCM, the ratio of RNs to licensed practical nurses (LPNs) has increased throughout the system. Many LPNs are studying to become RNs, and some RNs have begun bachelor degree programs. Several RNs are pursuing graduate degrees. We have also experienced an increase in interest in nursing certification. The shift in educational preparation and certification has led to a noticeable improvement in evidence-based thinking and practice.
The Practice and Quality Councils are responsible for supporting the implementation of evidence-based care at JGS. Several evidence-based protocols have been developed and implemented for procedures such as intravenous flush and conditions such as hypoglycemia. The Research Council was created to support nurses who are interested in creating new knowledge and serves as a conduit for nurse scholars from outside the agency who wish to conduct research at JGS.
Together with the resident, the staff nurse is at the center of the JGS-CCM. To form an effective team for health management, several kinds of resources must be available for the care required. First, the nurses must have current and timely information on procedures and medications. JGS has implemented an online procedure manual. The nurse must also have access to timely medical support. The medical director and nurse practitioners are available daily to help the staff nurse and resident evaluate changes in the resident’s health status. Nurse clinical specialists and certified nurses provide consultation on the management of complex health problems. Finally, the nursing leadership team has embraced the JGS-CCM and has made a commitment to support model implementation by creating infrastructure that supports the relationship between nurses and residents.
Clinical information is available online. All nurses have computer access and an e-mail account. In addition to the procedure manual mentioned above, each nurse’s computer desktop has several links to nursing websites, such as the Nurses Improving Care for Healthsystem Elders project ( http://www.nicheprogram.org), and other websites with reliable geriatric nursing information.
Clinical Information System
We evaluated our documentation system to determine how we can best capture the essence of resident self-management and revised our care plan to include self-management goals. The Practice Council provides the foundation for autonomous nursing practice using evidence-based practice designs. Finally, we are in the early stages of implementation of an electronic resident health record. We are including the JGS-CCM in our documentation redesign.
Congruence between our professional practice model or middle range theory of nursing—the JGS-CCM—and the current body of nursing literature regarding middle range nursing theory, was established by the nursing leadership team. We explored the current literature describing middle range nursing theories focused on nursing practice with individuals with chronic illness. For example, as noted above, our definition of the person is similar to the current conceptualization of the individual with chronic illness (Grey et al., 2006; Hennessey & Suter, 2009; Thorne & Paterson, 1998). In addition, it is consistent with the definition of the individual in the Scope and Standards of Gerontological Nursing Practice (American Nurses Association, 2001). Our definition of the environment is evidence based in that it was identified in a thesis conducted by an undergraduate nursing student (White, 2006). The conceptualization of health as self-management is also consistent with the current middle range theories of managing chronic illness. Our conceptualization of nursing is unique, evolving from the original CCM, the Massachusetts Nurse Practice Act, and the beliefs and actual practice of our nurses.
As new care settings are invented and existing settings are reinvented for care of older adults, creating systems where the older adult is an active participant in the decision-making process is essential. Early evidence suggests that implementing the JGS-CCM has transformed the way care is provided in our setting. Implementation of the JGS-CCM has provided a framework to potentiate the interaction and communication among informed residents, their families, and a knowledgeable interdisciplinary team led by a nurse. The JGS-CCM has developed into a middle range nursing theory designed to explain the interactions among the nurse, resident, health, and the postacute care environment.
Although we are still growing into our professional practice model, we are confident the model meets the four goals we determined were important. The model adequately describes postacute care nursing practice, it encompasses the four aspects of the metaparadigm of nursing and promotes nursing professional practice, and it can be used by the entire facility as a framework for practice. Through implementation of the JGS-CCM, nurses and the entire health care team have changed their daily practice. Because of an expanded view of chronic and long-term care and an integrated way to view the care we provide, our nurses are delivering care that is more congruent with the needs of our residents. In addition, residents and their families are assuming a greater role in planning and implementing their health care and engaging in more decision making with respect to their daily lives. Having spent the past 2 years implementing the model, in the next year or two, we will begin to use the model as a framework for the discovery of new knowledge. Adapting the model to our postacute care system has helped us improve care for our residents and improve their control over their lives.
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