Six Domains of Care Assignment
Six Domains of Care Assignment Paper
Six Domains of Care Assignment Paper
Assessing the Effectiveness of Care as One of the Six Domains of Care: An Example of Three Diabetes Care Interventions by a Primary Care Family Nurse Practitioner
The Family Nurse Practitioner (FNP) responsible for primary health care has the important role of managing patients with undifferentiated medical conditions at the first point of contact with healthcare services. As such, the FNP treats both chronic and acute illnesses as well as educating patients on measures aimed at the prevention of disease. However, these healthcare services provided by the FNP must not only be cost-effective, but also of high quality. This is what was envisaged by the drafters of the Patient Protection and Affordable Care Act 2010. What this means is that there must be a way of evaluating and assessing the quality of healthcare services delivered by the FNP and other clinicians. This is one of the reasons why the National Committee for Quality Assurance (NCQA) was established, with the singular goal of improving the quality of healthcare. This committee is responsible for evaluating the quality of healthcare provided by such healthcare professionals as the FNP. The information on healthcare quality collected by the NCQA is crucial and beneficial to both patients and payers in making informed choices on which healthcare services are the best (NIDDK, n.d.). Likewise, the Healthcare Effectiveness Data and Information Set (HEDIS) aggregates, consolidates and analyses collected quality of healthcare information from providers. It uses close to one hundred sets of criteria to assess for the quality of healthcare in all the six domains of care (NCQA, 2020). This paper discusses three type 1 diabetes interventions to be used as parameters for evaluating the effectiveness of care as one of the six domains of care. Six Domains of Care Assignment Paper
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One of the Six Domains of Care
Effectiveness of care is a performance measure used to evaluate quality healthcare and is one of the six domains of care. It is the one chosen for this analysis of diabetes services provided by the FNP. According to the Agency for Healthcare Research and Quality (AHRQ, 2018), effectiveness means the use of only evidence-based interventions in practice. These interventions must not only be those that are beneficial to the patient, but also that guarantee improved patient outcomes. The interventions must also be safe, timely, and efficient. The NCQA and HEDIS provide the analytical framework for assessing the quality of healthcare which is effective, patient-centred, and equitable (AHRQ, 2018).
A 22 Year-Old Caucasian Male with Type 1 Diabetes Mellitus
To clearly demonstrate effectiveness as a domain of quality healthcare provided by the FNP in question, one of her patients with type 1 diabetes is taken as a reference point. This is a 22 year-old Caucasian male who has had diabetes since childhood. The three different diabetes interventions for effectiveness as a performance measure are inspired by the Diabetes Recognition Program (DRP) of the National Committee for Quality Assurance (NCQA, 2019). They are:
HbA1c control in type 1 diabetes
Assessment of nephropathy development, and
The control of blood pressure in a type 1 diabetic.
In all these three interventions, the question asked by the FNP is whether there are any deficiencies in their effectiveness. This she achieves by looking at the health goal against the quality goal (WHO, 2006). The DRP helps to guide practitioners like the FNP in providing quality efficient, effective, patient-centered, timely, safe, and equitable diabetic care (NCQA, 2019). Six Domains of Care Assignment Paper
Controlling HbA1c Levels in Type 1 Diabetes
HbA1c is glycated hemoglobin and the blood test is an indicator of what the patient’s average blood sugar level has been in the last three months. When the blood sugar is high, some of the sugar gets attached to the hemoglobin molecule in the blood. HbA1c is, therefore, a percentage of the blood sugar attached to the hemoglobin or Hb (Hammer & McPhee, 2018). To implement the intervention of controlling the HbA1c levels, the FNP tests the HbA1c level of this 22-year-old after every three months. Meanwhile, she ensures that his blood sugar levels remain within normal limits throughout by prescribing insulin, asking him to check his blood sugar at home daily and to keep a record of the readings, teaching him healthy eating habits, encouraging him to exercise, and keeping his body mass index or BMI below 25. The FNP has put him on the intermediate-acting insulin Humulin N 0.5 unit/kg/day in divided doses for a year now.
As earlier stated, to measure the patient outcomes the FNP has been checking the blood HbA1c levels of this patient quarterly for the past one year. The health goal is to keep the HbA1c level low, and the quality goal is to maintain a HbA1c level below 6.9%. So far, the FNP has managed to keep the HbA1c level between 48 and 52 mmol/mol (6.5-6.9%) the whole year. The blood sugar has also been maintained at 80-130 mg/dL before meals and up to 180 mg/dL postprandial. In a study by Lind et al. (2019), the researchers found that high HbA1c levels are associated with increased complications such as retinopathy and nephropathy in type 1 diabetics. They concluded that a HbA1c level of 8.5% (70.5 mmol/mol) and above had a high risk of eye and kidney damage. However, a level of 6.5 to 6.9% was associated with a significant reduction in the risk of organ damage (Lind et al., 2019).
Assessment of Nephropathy development
Kidneys that have suffered damage will let more and more albumin pass into the urine. Diabetic nephropathy results from progressive glomerular insufficiency over time which finally leads to frank albuminuria (Narva & Bilous, 2015). In implementing this intervention in this 22 year-old patient, the FNP has been performing monthly dipstick tests for albuminuria. Measurement of the outcome has revealed good news so far in that the albumin level in his urine has been consistently kept below 30mg/dL or 300 mg/day (Narva & Bilous, 2015). This is normal and the FNP intends to keep him that way.
The Control of Blood Pressure in a Type 1 Diabetic
High blood pressure is one of the main problematic conditions that diabetic patients have to deal with (Huether & McCance, 2017). In the case of this 22-year-old patient, the FNP has managed to implement blood pressure control by putting him on the calcium channel blocker verapamil and the centrally – acting antiadrenergic methyldopa. The FNP has been having this patient on verapamil 200 mg nocte and methyldopa (Aldomet) 250 mg TDS for close to one year (Katzung, 2018). According to Ovalle et al. (2018), verapamil reduces the requirement for insulin, reduces the number of hypoglycemic incidents, and lowers the blood pressure (BP). Methyldopa on its part has the added advantage of being cardioprotective. The FNP has managed to measure the patient outcome at every visit through taking a BP reading. To date, she has managed to control the pressure and keep it between 110/80 and 130/90 mmHg.
Savings on Cost and Nurse Practitioner Ratings
All the three primary care interventions above result in improved patient outcomes by showing consistently normal or near-normal results. This is the case with this patient as has been shown above. By keeping the patient outcomes favorable as above, morbidity of the patient is greatly reduced. This translates to fewer hospital visits and fewer expenditure on drugs, hence cumulative cost savings.
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These interventions can also result in improved nurse practitioner ratings for the FNP when this patient’s data gets to HEDIS (NCQA, 2020). Also, the FNP can apply to the Diabetes Recognition Program (DRP) of the NCQA with this patient’s effectiveness data. The DRP will then officially recognise the FNP as a deliverer of quality primary health care. Six Domains of Care Assignment Paper
Conclusion
Quality healthcare is an essential component of any healthcare system in a country. This quality must be measurable and must be associated with affordability, safety, efficacy and effectiveness. Above all, the quality healthcare services must be equitable. The FNP in this case has demonstrated effectiveness of her interventions as one of the six performance indices or domains of care.
References
Agency for Healthcare Research and Quality [AHRQ] (2018). Six domains of health care quality. Retrieved 20 January 2020 from https://www.ahrq.gov/talkingquality/measures/six-domains.html
Hammer, D.G., & McPhee, S.J. (Eds). (2018). Pathophysiology of disease: An introduction to clinical medicine, 8th ed. New York, NY: McGraw-Hill Education.
Huether, S.E. & McCance, K.L. (2017). Understanding pathophysiology, 6th ed. St. Louis, MO: Elsevier, Inc.
Katzung, B.G. (Ed) (2018). Basic and clinical pharmacology, 14th ed. New York, NY: McGraw-Hill Education.
Lind, M., Pivodic, A., Svensson, A., Ólafsdóttir, A.F., Wedel, H. & Ludvigsson, J. (2019). HbA1c level as a risk factor for retinopathy and nephropathy in children and adults with type 1 diabetes: Swedish population based cohort study. BMJ, 366, l4894, doi:10.1136/bmj.l4894
Narva, A.S. & Bilous, R.W. (2015). Laboratory assessment of diabetic kidney disease. Diabetes Spectrum, 28(3), 162–166, doi: 10.2337/diaspect.28.3.162
National Committee for Quality Assurance [NCQA] (2020). HEDIS and performance measurement. Retrieved 20 January 2020 from https://www.ncqa.org/hedis/
National Committee for Quality Assurance [NCQA] (2019). Diabetes Recognition Program (DRP). Retrieved 20 January 2020 from https://www.ncqa.org/programs/health-care-providers-practices/diabetes-recognition-program-drp/
National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK] (n.d.). National Committee for Quality Assurance (NCQA) overview. Retrieved 20 January 2020 from https://www.niddk.nih.gov/health-information/communication-programs/ndep/health-professionals/practice-transformation-physicians-health-care-teams/team-based-care/patient-centered-medical-home/national-committee-quality-assurance-overview
Six Domains of Care Assignment Paper
