Unnecessary hospital readmissions adversely impact Medicare beneficiaries as well as hospitals. Historically, one in five Medicare beneficiaries is readmitted within 30 days of discharge; as many as three in four of these readmissions may be preventable (McIlvennan et al., 2015; Panagiotou et al., 2019). Hospital readmission is costly; unnecessary hospital readmissions cost taxpayers an estimated $12 billion annually (McIlvennan et al., 2015; Mittal et al., 2018). Over recent decades, hospitals have used nurses to provide priority transitional care interventions (TCIs) such as medication reconciliation, case management, frequent contacts, education, caregiver support, and patient self-management support (Gilmartin et al., 2022; Naylor et al., 2004).
Faith community nurses (FCN) provide TCIs, but little has been written describing these interventions. This description of transitional care illuminates the role of the FCN in delivering transitional care to high-risk seniors and may provide a wholistic model of transitional care for duplication. The focus of this article is to describe TCIs delivered by an FCN to 129 at-risk seniors over a 2-year period (2018-2019).
BACKGROUND
A strategy to decrease hospital readmissions and impact Medicare spending is outlined in the Patient Protection and Affordable Care Act (Cutler et al., 2010; Naylor et al., 2011, 2012). The Independent Payment Advisory Board created the Continuity Assessment Record and Evaluation Medicare Tool to measure the health and functional status of Medicare patients at discharge from hospitals and determine payment reimbursement (Smith et al., 2012). As part of the strategy, payment penalties began in October 2012 for hospitals subject to the Inpatient Prospective Payment System. In 2014, hospitals lost 3% of every Medicare payment if the hospital had an excessive 30-day readmission rate for three specific diagnoses: acute myocardial infarction, congestive heart failure, and pneumonia. In 2015, exacerbation of chronic obstructive pulmonary disease and total hip and knee arthroplasty were added. In 2017, coronary artery bypass surgery was added as an additional diagnosis penalizing hospitals financially for unnecessary 30-day readmissions (Centers for Medicare & Medicaid Services, 2022).
In 2012, a hospital in Desoto, Mississippi, decided to implement the Better Outcomes by Optimizing Safe Transitions (BOOST) program to 1) identify patients at high risk of rehospitalization and target specific interventions to mitigate potential adverse events; 2) reduce 30-day readmission rates; 3) improve patient satisfaction scores related to discharge; 4) improve flow of information between hospital and outpatient healthcare providers; 5) improve communication between providers and patients; and 6) optimize discharge processes (Jha, 2013). Even with BOOST in place, the hospital provided care to many repeat emergency department (ED) admissions over 20 months. Patients were using the ED as their medical home, which led to increased ED staffing and an increase of uncompensated care. As part of the solution, the hospital leadership employed an FCN to deliver transitional care from hospital to home (Jha, 2013).
Nursing Interventions Classification System
The latest 7th edition of the Nursing Interventions Classification (NIC) system includes interventions that nurses can do on behalf of patients (Butcher et al., 2019). An intervention is "any treatment, based upon clinical judgment and knowledge, that a nurse performs to enhance patient/client outcomes" (Butcher et al., 2019, p. xii). Each NIC intervention is aligned to activities to enhance patient outcomes, based upon clinical judgment and knowledge. In the NIC 7th edition, 565 nonduplicated Interventions (with 91 duplicated Interventions) are grouped into 30 Classes and seven Domains. Duplications occur in NIC when interventions are repeated in more than one class. Each NIC has its own numerical code (645 codes) and definition (554 definitions). Underpinning each standardized NIC are 13,000 nonstandardized nursing activities. Howard Butcher, editor of the 7th edition of NIC, offers a helpful overview of NIC in his free, online presentation, Integrating the Nursing Interventions Classification (NIC) Into Nursing Education and Practice (Butcher, 2017).
This study describes the TCIs delivered by one FCN using the NIC system. Standardized nursing language from NIC was used to describe the FCN's interventions because historically, NIC is "...readily understood by all nurses, to describe care" (Keenan, 1999, p. 12). In addition, FCN researchers have previously used NIC to describe FCN interventions (Burkhart & Androwich, 2004; Solari-Twadell & Hackbarth, 2010; Weis et al., 2002).
FCN ROLE IN TRANSITIONAL CARE
The FCN is a registered nurse who has received additional education to deliver care coordination and incorporate spiritual health interventions. The FCN works with or in faith communities, understanding the unique culture that exists (American Nurses Association & Health Ministries Association, 2017). Ziebarth and Campbell (2016) stated that the use of an FCN to deliver transitional care brings two benefits: 1) a wholistic healthcare approach to caring, and 2) the additional support of a faith community. The essence of wholistic care is to help a person attain or maintain whole health (Wolf, 2008). The wholistic approach used in this study addressed the spiritual, physical, mental, and social dimensions of health. Wholistic health is defined as "...the human experience of optimal harmony, balance and function of the interconnected and interdependent unity of the spiritual, physical, mental, and social dimensions" (Ziebarth, 2016, p. 22).
The conceptual model of faith community nursing defines and clarifies the practice of the FCN. The practice of faith community nursing is described as
A method of healthcare delivery that is centered in a relationship between the nurse and client (client as person, family, group, or community). The relationship occurs in an iterative motion over time when the client seeks or is targeted for wholistic healthcare with the goal of optimal wholistic health functioning. Faith integrating is a continuous occurring attribute. Health promoting, disease managing, coordinating, empowering, and accessing healthcare are other essential attributes. All essential attributes occur with intentionality in a faith community, home, health institution, and other community settings with fluidity as part of a community, national, or global health initiative. (Ziebarth, 2014, p. 1829)
As FCNs receive additional training to deliver spiritual care, implementing transitional care may look different than other nursing models. The Joint Commission (TJC, 2011) recognized that patients have specific characteristics and nonclinical needs that can affect the way they view, receive, and participate in healthcare. The Joint Commission (2022) now encourages healthcare organizations to assess and support spirituality. Supporting patients' spiritual needs may help them to cope with their illnesses. The FCN may ask questions like, "What sustains you during difficult times?" "Do your religious or spiritual beliefs influence the way you look at your disease and the way you think about your health?" (Ziebarth, 2017).
STUDY PURPOSE AND METHODS
All FCNs can deliver transitional care; however, there is limited information to describe these interventions. This description of transitional care illuminates the role of the FCN in delivering transitional care to high-risk seniors and may provide a model of transitional care for duplication. The purpose of this study was to describe transitional care delivered by an FCN using a standardized nursing language, NIC.
A quantitative study using documentation as ordinal data described TCIs delivered by one FCN in 2018 to 2019. This FCN delivered transitional care to 129 patients transitioning from a 150-bed hospital in Desoto, Mississippi, to their respective homes in a certain ZIP code. The hospital chose this region due to the large percentage of high-risk seniors being readmitted from the ZIP code. Deidentified nursing documentation was coded into NIC nursing language and counted to describe the FCN's TCIs. Percentages of NICs listed showed which interventions were used more often.
The FCN prescreened all participants prior to hospital discharge to ensure that the screening form was completed and that the person met the eligibility criteria. Eligibility criteria included discharged from hospital to home, willingness to accept home visits, and having a telephone to receive calls. Medicare patients living in a specific ZIP code area were targeted for the study, given that nearly 30% of all readmissions to the hospital came from that area. The project was explained, and an informed consent form was signed if the patient desired to participate. If a study participant had difficulty reading the consent form, the FCN assisted the participant in reading the form.
The investigative team served to insure proper data collection and safety monitoring. Prior to the study being initiated, an Institutional Review Board application was approved. All records were deidentified and kept in locked file cabinets in locked rooms.
The Faith Community Nurse Transitional Care Model (Ziebarth & Campbell, 2016; Figure 1) was the framework used in this study. The model is presented in a linear fashion moving from a predischarge phase to a postdischarge phase. During these phases, essential nursing interventions are to be implemented.
The FCN providing TCIs attended the Foundations of Faith Community Nursing Course 2014 edition which prepares the registered nurse for the specialty practice of faith community nursing (Jacob, 2014). Each course module has varying lengths ranging from 2 to 4 hours for 38 to 40.5 contact hours. The curriculum covers topics such as spiritual care, prayer, self-care, ethical issues, documenting practice, behavioral health, health promotion, life issues of violence, suffering and grief, and assessment and care coordination. The Foundations course now has a 2019 revision (Jacob, 2019). The FCN also attended a 1-day transitional care training.
Study participants were recruited by a visit in the hospital and at home by the FCN. The intervention plan included providing three transitional care visits. The first visit took place in the hospital prior to discharge. The second visit (first home visit) occurred within 48 hours after discharge. Visits with patients included nursing interventions such as medication review, screenings (vital signs), physical and safety assessments, acute and chronic disease(s) management and education, coordination of physician/clinic visits, and resources and referrals as needed. Socialization and spiritual components of visits were routine. During the third visit, the FCN accompanied the participant to their physician's visit to a) introduce self and role to the physician, b) facilitate information exchange between the patient and the healthcare provider, and c) ensure that the patient and caregiver(s) were fully engaged and participating in healthcare decisions. Length of transitional care provided by the FCN was determined by diagnoses and program outcomes, but generally did not exceed 60 days. There was no cost to patients receiving the FCN transitional care service; the FCN was a paid hospital employee.
Volunteers from a local faith community were asked by the FCN to provide certain services with the verbal consent of the participant as soon as possible after hospital discharge. These services included encouraging correspondence (cards) from others, friendly visits (in-person or phone calls), meals, and/or transportation. The FCN later found sustainable county-supported programs for transportation and meals.
DOCUMENTATION, DATA COLLECTION, ANALYSIS
The FCN in this study initially documented in a narrative format using a nursing note, which was translated by the researchers into a nursing intervention using the NIC taxonomy (Butcher et al., 2019). Later, the Henry Ford Macomb's (HFM) electronic tool (Henry Ford Health, 2022) was used to document nursing interventions. This tool was developed for FCNs using the NIC format to describe nursing interventions.
The FCN documentation was obtained through a collaboration between the hospital and Church Health (CH), a wholistic health center in Memphis, Tennessee. A nurse employed by CH collected the raw FCN documentation from the hospital electronically and removed patient identifiers before transmitting data to the researcher in two forms: 1) NICs as documented in the HFM electronic tool, and 2) nursing notes. Data were then downloaded onto a password-protected Universal Serial Bus drive to store for analysis.
The Nursing Intervention Classification Analysis Program (NICAP) is a data management program developed by one of the authors (Lane) with the capacity to collect and organize large numbers of individual NICs into a manageable database for analysis. In preparation for NIC collection, analysis, and translation, all NICs delivered by the FCN were entered manually into the NICAP. Each nursing intervention in NIC had its own identifying numerical code (n = 645) and definition (n = 554). In addition, the established 30 classes and seven domains of NIC were entered, along with definitions that aligned to nursing interventions. All NICs documented electronically by the FCN were entered into NICAP.
Nursing interventions also were documented in nursing notes, which were analyzed thematically by the investigators using data reduction, interpretation, and translation. The data were reduced when nursing intervention descriptors were underlined electronically. Microsoft Word computer-generated highlighted colors were used to categorize similar nursing intervention descriptors to assist with interpretation of the data. The nursing intervention descriptors were then translated into NICs and entered into NICAP.
FINDINGS
The FCN made 862 total visits: in the home (170); via phone (329); physician's office (128); hospital (167); rehab (29); dying care/hospice/funeral (5); faith community (1); office (2); community setting (9); food pantry (4); ED (1); long-term care (2); and other (16). It was noteworthy that no visits occurred by email, video conference, or text.
Of the 565 nonduplicating nursing interventions, 51(10.9%) were reported to have been used at least once, with a total of 2,280 interventions documented. The FCN averaged 2.7 NICs per patient visit. A total of 2,280 interventions were documented with 28 NICs describing the bulk of TCIs provided by the FCN. Twenty nursing interventions represented 64% (n = 1459) of the 2,280 NICs (see Table 1).
An NIC class contains a standardized group of interventions representing various nursing activities. There are 30 classes in the NIC system; 17 classes that represent all seven NIC domains were used by the FCN in this study (see Table 1). Most interventions belonged to the behavioral domain (52.9%) which is defined as "care that supports psychosocial functioning and facilitates life-style changes" (Butcher et al., 2019, p. 40). The behavioral domain includes six classes of interventions that contain specific interventions such as Decision-making Support, Spiritual Support, Patient Education, Coping Assistance, and Communication Enhancement. The three classes containing the most frequently reported interventions (77%) were Coping Assistance, Communication Enhancement, and Patient Education (all in the behavioral domain).
The second most prominent domain represented was that of health system, which is defined as "care that supports effective use of the health care delivery system" (Butcher et al., 2019, p. 40). Information Management and Health System management were the most frequent classes used.
The third domain identified as significant was Physiological: Basic, defined as "care that supports physical functioning" (Butcher et al., 2019, p. 40). The FCN used the classes of Physical Comfort Promotion, Nutrition Support, and Immobility Management to document NICs. The fourth domain of Physiological: Complex, is defined as "care that supports homeostatic regulation" (Butcher et al., 2019, p. 40). The only class used in this domain was drug management. The fifth domain used was the Family Domain, which is defined as "care that supports the family unit" (Butcher et al., 2019, p. 40). In this domain, the only class used was Lifespan Care. The sixth domain is Safety, defined as "care that supports protection against harm" (Butcher et al., 2019, p. 40). Risk Management was the only class used to document NICs. Only a few interventions were selected in the Community Domain. The Community Domain represents activities that occur in the community such as health screenings and meetings.
DISCUSSION
Study results indicate that this FCN provided similar activities to those found to be priorities in previous transitional research: follow-up calls, medication reconciliation, case management, education, caregiver support, and patient self-management support (Naylor et al., 2004). In addition, the FCN provided spiritual support, forgiveness facilitation, and religious ritual enhancement. The findings are consistent with other faith community nursing research studies that found that FCNs provide both nursing and spiritual support for anxious and isolated elders as they prevent crisis care or hospital readmissions (Rydholm et al., 2008).
The fact that the FCN provided both priority and spiritual support interventions is important for three reasons:
* Some patients may seek out healthcare providers who include spiritual support interventions in addition to symptom management (Dyess et al., 2010).
* Supporting patients' spiritual needs may help them to cope better with their illnesses, changes, and losses in life (TJC, 2022).
* This FCN provided a wholistic approach to transitional care provision by addressing the spiritual, physical, mental, and social dimensions of health.
Implications and Limitations
The FCN is in a unique position to deliver easily accessible healthcare services to specific populations because they are community-based and working in or with faith communities. This study supports that a) the FCN Transitional Care Model can be operationalized; (b) the NIC system can be used to describe transitional care provided to patients by an FCN; and (c) the FCN delivers priority nursing interventions as well as spiritual support interventions.
A limitation of the study is that cognitive-impaired diagnosed patients were not included as their inclusion would have involved seeking alternative consent from guardians.
Another limitation is that the FCN had complete autonomy in choosing what interventions to document and could have incorrectly chosen NICs from the Henry Ford system. Finally, care from only one FCN was used for this study; thus, results may not be generalizable.
CONCLUSION
Priority TCIs in this study were delivered by an FCN to 129 high-risk senior patients discharged from hospital to home and living in a certain ZIP code. The FCN documented interventions, which were translated into NICs and analyzed. The data showed that priority TCIs were captured in the documentation. In addition, spiritual care support was provided. Using an FCN to provide transitional care should be considered when a wholistic approach is valued. The FCN is knowledgeable and comfortable working in healthcare settings and in/with faith communities. This unique approach to transitional care may reduce readmissions, help patients cope better with illness, and maintain or improve wholistic health.
Acknowledgment
This study was part of a larger "Parish Nurse Study" between Baptist Memorial Hospital-DeSoto, the Baptist Clinical Research Institute, Church Health, and the University of Memphis School of Public Health. The complete study was funded by the Ford-Goltman Cardiovascular Research Endowment and the Baptist Memorial Health Care Foundation. Study # 14OG11.
Web Resources
* Center for Nursing Classification and Clinical Effectivenesshttps://nursing.uiowa.edu/center-for-nursing-classification-and-clinical-effecti
* Whole-Person Transitional Carehttps://www.ahrq.gov/patient-safety/settings/hospital/resource/guide/index.html
* Henry Ford Macomb FCN Documentation Systemhttps://www.henryford.com/locations/macomb/about/community-outreach/spiritual-su
* NIC in the Era of the Electronic Health Care Recordhttps://slideplayer.com/slide/13649963/
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