Journal of Managed Care Nursing, Volume 7, Number 2

Vol. 7, No. 2 & 3, December 2020

Call for Articles

Journal of Managed Care Nursing Interested writers are requested to submit their editorial or research articles!

The JMCN publishes topics on managed care and related subjects, like quality & utilization management, patient advocacy, current trends, changing legislature, leadership tips, and more.

For more information on submitting an article, contact Jackie Beilhart at jbeilhart@aamcn.org or view the author guidelines at www.aamcn.org/jmcn.html

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JMCN JOURNAL OF MANAGED CARE NURSING 4435 Waterfront Drive, Suite 101 Glen Allen, VA 23060 EDITOR-IN-CHIEF Jacqueline Cole, RN-BSN, MS, CNOR, CPHQ, CMCN, CHC, CHPC, FNAHQ, FAHM, FHIAS PUBLISHER Jeremy Williams VICE PRESIDENT OF COMMUNICATIONS Jackie Beilhart JOURNAL MANAGEMENT American Association of Managed Care Nurses 4435 Waterfront Drive, Suite 101 Glen Allen, VA 23060 phone (804) 747-9698 fax (804) 747-5316 MANAGING EDITOR Jackie Beilhart jbeilhart@aamcn.org GRAPHIC DESIGN Jackie Beilhart jbeilhart@aamcn.org

Journal of Managed Care Nursing The Official Journal of the AMERICAN ASSOCIATION OF MANAGED CARE NURSES A Peer-Reviewed Publication Vol. 7, No. 2 & 3 A Joint Issue December 2020 TABLE OF CONTENTS Articles Health Literacy, Health Confidence, and the Connection to Readmissions Colleen Morley, Ellen Walker . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The Inside Approach to Outreach Programs Tatia Sheppard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Implementation of Corrective Measures Using the Simulation before Admitting COVID-19 Patients to a Hospital Stefanos Digonis, Paschalis Tasoudis . . . . . . . . . . . . . . . . . . 11 Home Care Rapidly Adapts to Impacts of COVID-19 Shining a Light on Importance of Care at Home Lakelyn Hogan, LaNita Knokes. . . . . . . . . . . . . . . . . . . . . . . .15 Compassionate Care: The Missing Link in Clinical Integration Bonnie Zickgraf. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Newly Certified Managed Care Nurses (CMCNs) . . . . . . . 23 Author Submission Guidelines . . . . . . . . . . . . . . . . . . . . . .25

ISSN: 2374-359X. The Journal of Managed Care Nursing is published by AAMCN. Corporate and Circulation offices: 4435 Waterfront Drive, Suite 101, Glen Allen, VA 23060; Tel (804) 747-9698; Fax (804) 747-5316.

Advertising Offices: Jackie Beilhart, 4435 Waterfront Drive, Suite 101, Glen Allen, VA 23060 jbeilhart@aamcn.org; Tel (804) 7479698. All rights reserved. Copyright 2020.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage or retrieval system, without written consent from the publisher. The publisher does not guarantee, either expressly or by implication, the factual accuracy of the articles and descriptions herein, nor does the publisher guarantee the accuracy of any views or opinions offered by the authors of said articles or descriptions.

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Health Literacy, Health Confidence, and the Connection to Readmissions Colleen Morley, DNP, RN, CCM, CMAC, CMCN, ACM-RN (1) & Ellen Walker MSW, LCSW, ACSW (1) 1. West Suburban Medical Center

Case managers have long made the connection between Social Determinants of Healthcare (SDoH) and increased risk for readmission through anecdotal observation. Failure to create overarching strategies to address the gaps caused by SDoH continues to impact the care continuum’s ability to adequately equip the patient for success post-discharge.

that you can control and manage most of your health problems?” Rated on a scale of 0 (not confident) to 10 (very confident), with a desired response of 7 or higher; this single question can start a meaningful conversation between practitioner and patient and lead to increased health literacy, understanding, and engagement.

One of the leading SDoH factors has been identified as health literacy, defined by the Agency for Healthcare Research and Quality as “the degree to which an individual has the capacity to obtain, process and understand basic health information and services needed to make appropriate health decisions.”1 Health literacy differs from “basic literacy” by being more than the basic ability to read. According to Linda Jordan BSN RN, MHCM from The Joint Commission, “everyone, no matter how educated, is at risk for misunderstanding health information, especially if the issue is emotionally charged or complex.”1 Further complicating the communication between healthcare providers and healthcare consumers is the potential for misunderstanding the information presented but feeling embarrassed to ask questions, seek clarification or confirm their understanding.

A review of literature demonstrated that addressing the patient point of view through survey of risk focused on SDoH has been successful at creating better linkage and access to care/services needed by patients to self-manage their heath. Using a survey tool based on the “PRAPARE” survey (used in outpatient settings), CM RN & SW surveyed all readmitted patients and identified and addressed gaps in self-management by providing community resources and services. This had a minimal impact on the readmission rate for this patient population.

Health literacy has a major impact on patient engagement or activation. Dr. Eric Coleman notes that “engaged patients have better health outcomes and better healthcare experiences, and are likely to use fewer healthcare services and cost the healthcare system less in case dollars.”2 One measure of patient engagement is “health confidence” scoring, measured by the response to a single question: “How confident are you

The results obtained from this survey in the first three month’s data collection demonstrated that the primary self-identified reason for readmission was lack of understanding of the discharge instructions provided. After this initial evaluation, the health confidence scoring tool was added to our survey. Of the 146 patients surveyed between November 2018 and July 2019, the average Health Confidence Score was 6.41 out of 10.

This finding was interpreted as this patient population needed more intense case management interventions and more focused education to better prepare them for discharge and independent condition management. (fig 1)

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Figure 1

The most significant finding in our study was the lack of follow through with post-discharge follow up appointments. 147 follow up appointments were made for the patients pre-discharge (with their input as to date/time). 69 patients attended this appointment (46.93% adherence) and 78 patients failed to attend their scheduled appointment (53.06% non-adherence). (fig 2) Figure 2

Figure 3

Recognizing that responsibility for the patient in this healthcare environment does not end at the discharge from the hospital, conclusion of service, or end of the appointment, addressing patient health literacy and health confidence is as much a necessity as identifying patient’s extra-medical needs and linking them with needed services and resources to provide the patient with excellent patient-centered care and promote client self-advocacy and independence in alignment with the CMSA Standards of Practice.

REFERENCES

Access to prescription medications was not noted to be an issue; over 95% of participants reported access to their new/renewed prescription medications within 24 hours post discharge. Other social issues, such as, transportation, language barrier, or other social issues contributed to an average of 2 patients monthly. (fig 3)

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1. Jordan, L (2016). Health literacy made simple. The Joint Commission, November, 2016.

2. Wasson, J., & Coleman, E. A. (2014). Health confidence: an essential measure for patient engagement and better practice. Family Practice Management, 21(5), 8–12.

3. Nunlist, M. M., Blumberg, J., Uiterwyk, S., & Apgar, T. (2016). Using Health Confidence to Improve Patient Outcomes. Family Practice Management, 23(6), 21–2

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The Inside Approach to Outreach Programs Tatia Sheppard, RN, CCM, CCWS, CMCN (1) 1. Nova Healthcare Administrators

Summary As health plan participants modify behaviors or adapt to plan changes, new information will emerge.

Data analysis needs to be ongoing. Therefore, educational aspects of outreach programs are invaluable. It is important to view plan recommendations and strategies through the lens of the plan sponsor and the plan participant. Employers understand their tolerance for change. And they know their employees best. With the right partner to engage in conversations, each possibility for data review provides another opportunity for conversation around improving plan performance and health outcomes.

Key Points • Reduce inappropriate utilization of Emergency Room (ER) visits • Avert complications and prevent readmissions • Improve member care needs by linking members to a primary care doctor or specialist to manage care appropriately • Identify members for case management opportunities who may need assistance in navigating the health care delivery system, education and support to enhance their understanding of their condition, and treatment to avoid complications/exacerbation Working in the health care industry has taught me many things. One of the most important lessons: you must have a plan. The key to integrated medical management program success is to help participants coordinate care through the development of an individualized care plan to meet their needs by ensuring the participants have the necessary tools and support to achieve optimum health and improved self-management, in the most appropriate setting and cost-effective manner.

The problem is many members use the emergency room (ER) inappropriately for treatment of non-lifethreatening conditions increasing the cost for unnecessary or inappropriate services. Common barriers include the lack of knowledge, geographical location (ER is closer, no urgent care facility nearby), no Primary Care Physician (PCP) or lack of access and/or knowledge of PCP sick visit process, chronic condition exacerbations, and/or lack of transportation.

As clinical data cycles, trends will become evident and

assist in the development of building program strategies that provide employees with rich benefits while remaining cost-effective for health plans. However, what happens between the data reporting and overall outcomes are the real opportunities to promote change: identifying members who may need assistance in navigating the health care delivery system.

There are three phases to this process: • Understanding the importance of engaging members by assisting them in securing a primary care physician. This increases compliance and reduces the amount of ER visits.

• Learning how having real-time conversations with members aids in reducing complications and admissions; Hear how pre and post hospitalization outreach to members also serves as an education resource.

• Discovering how adopting strategies based on data can have a positive impact on plan performance and health outcomes.

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APPROACH Emergency Room Utilization and Pre- and Post-Hospitalization Outreach and Engagement The objectives of this program are to reduce inappropriate utilization of ER visits, improve member care needs by linking them to a primary care doctor or specialist, and identifying members for case or disease management opportunities who need assistance navigating the health care delivery system or education and support to improve self-management of their conditions. Through various outreach processes and member participation factors program closure reasoning varies.

Real-Time Conversations and Information Sharing A successful approach to treatment plan compliance include targeted outreach campaigns to plan participants with chronic conditions. Additionally, when clinicians work one-on-one with plan participants, they are able to help them address their needs and address potential barriers to care. Information sharing with physicians can help connect the dots to improve communication with the provider and patient to address behaviors that often result in urgent and emergent care. At Nova, we use our patient health summary (medication, labs, utilization) to bring all of the data points together so clinicians have access to a comprehensive view of each patient. By assessing the member’s understanding of upcoming procedures and admissions, reinforcing the physician’s treatment plan, and assisting with facilitation of appropriate discharge services, pre-and post-hospitalization outreach programs experience greater success in promoting optimal health and reducing readmission.

Disease Management models. They are innovative; yet, they generate results.

Engage members by assisting them in securing a primary care physician. This reduces the amount of ER visits.

• Conduct real-time conversations with members aids in reducing complications and re-admissions; Hear how pre and post hospitalization outreach to members also serves as an education resource to improve their understanding of their recovery to support optimal recovery outcomes.

• Adopting strategies based on data can have a positive impact on plan performance and health outcomes.

RESULTS Engaging members, assisting them in securing a primary care physician can reduce the amount of ER. Conducting real-time conversations with members aids in reducing complications and re-admissions; on our end, we get to hear how pre and post hospitalization outreach to members also serves as an educational resource to improve their understanding of their recovery to support optimal recovery outcomes. Adopting strategies based on data can have a positive impact on plan performance and health outcomes.

Below are some results and trends Nova’s plans and our Health Plan Performance Management department have observed from delivering a personal experience to meet plan participants’ specific needs.

Adopting Strategies Based on Data Effective plan management begins and ends with data; what matters is what you do with it. When it comes to consuming health plan data, you must keep asking questions. Why is this happening? What is driving cost? Where are plan participants seeking services?

How can we manage it? You need a strategic approach to plan analysis. To create the most impact and yield the best outcomes, it is important to remember that the most cost-effective strategies do not fit into the traditional Utilization Management, Case Management, or 8

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In the end, every health plan population has unique challenges that require the right course of action to bring about better health outcomes and sustainable savings. Collaboratively developing individualized care management plans is the key to promoting improved health across the continuum of care. When an individual reaches the optimum level of wellness and functional capability everyone benefits.

ARTICLE INFORMATION About the Author: Tatia Sheppard RN, CCM, CCWS, CMCN is the Director, Clinical Programs Strategy at Nova Healthcare Administrators, Inc. in Buffalo, NY, where she focuses on identifying opportunities to control medical expense and ensuring benefits support health management strategies. Tatia has more than 22 years of experience in the health care industry, including nearly 18 years in managed care medical management, ensuring the appropriate utilization of services and improving the health status of members. Tatia holds a nursing degree and is certified as a case manager, corporate wellness specialist, and certified managed care nurse. She is also an active board member of the Buffalo New York Chapter of American Diabetes Association.

AAMCN Would Like to Recognize Our Corporate Partners Foundation Medicine, Inc. Gilead Sciences, Inc. Home Instead Senior CareÂŽ Humana, Inc. Mallinckrodt Pharmaceuticals

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Implementation of corrective measures using the simulation before admitting COVID-19 patients to a hospital Stefanos Digonis BSN, RN, MSc(1) and Paschalis Tasoudis BSN, RN, MS(c), CPDAN(2) 1. Nurse, Dept of Internal Medicine Clinic, General Hospital of Thessaloniki “Georgios Gennimatas,” Central Macedonia, Greece; 2. Nurse, Student at MS(c) in Health Care Management, Dpt of Business Administration, University of Macedonia, Thessaloniki, Greece

Summary In this paper, we describe the potential of simulation to improve hospital responses to the COVID-19 crisis. We explain how simulation can help to improve responses to the crisis, what the key issues are with integrating simulation into organizations, and what to focus on when conducting simulations. We provide an overview of helpful resources of effective education and training design, delivery, and evaluation.

Key Points • Simulation can rapidly facilitate hospital preparation and education of large numbers of healthcare professionals and students of various backgrounds and has proven its value in many settings.

• People who make successful decisions have self-awareness, courage, sensitivity, energy and creativity.

• The rational approach to problem solving starts with a certain goal and ends with an evaluation process.

INTRODUCTION In the United States, evolving market forces, regional demographic trends, and advances in medical technology are contributing to a resurgent demand for hospital services, prompting many hospitals to create additional capacity.1 Expansion of existing hospital units and construction of new facilities challenge health care workers to devise ways of ensuring the safety and reliability of patient care processes amid significant changes in their physical surroundings. Immersive, full-environment (“in situ”) simulation exercises make it possible to prospectively determine whether newly built clinical facilities allow workflow patterns that foster safe and well-coordinated patient care. Several recent in situ simulation studies have provided important insights into the patient safety hazards that can

accompany the expansion of existing clinical service lines into a new clinical environment.1-2 Much has been learned for the past decades regarding the optimal means of providing simulation-based healthcare education to learners, but for these strategies to be of value to the community, they must be consistently translated into ongoing educational practice. 3-4 The Role of Simulation in the COVID-19 Crisis This is an unprecedented situation, and through it the simulation can be an opportunity to play an important role. This has been observed in previous crisis events inside and outside healthcare.5 Clinical care requirements are error-prone, and the risks are high if errors

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occur. The pandemic poses a high personal risk to the healthcare professionals themselves, possibly causing fear of infection or the spread of the infection to their family members. Education in the clinical environment is dangerous because of the risk of infection.

Simulation practice can reduce the cognitive burden of patient care staff, thus helping to reduce error during periods of stress and exhaustion.

In cases of a pandemic like the one we are experiencing, smart and new ways are needed to increase and upgrade a workforce, locate and supply equipment, and optimize work systems. Simulation can play a vital role in solving these problems, and simulation educators often have valuable capabilities to facilitate the necessary analytical work required to match (learning) needs, content, and methods for implementing effective interventions. Given the urgency, careful analysis of learning needs and simulation focus points is critical so that procedures are followed properly and resources are used appropriately to enable effective patient care. A beneficial first step is to look at what resources are available in terms of people, equipment, and location. Often, simulation mediators are trained in a systems security approach, understand the importance of feedback, and can guide people through targeted thinking. They often have an in-depth knowledge of the structure, procedures, and people of the hospital. Coordinators can use their skills to help healthcare facilities identify key issues that need to be addressed. They can help find solutions and connect different people and departments that will benefit from the collaboration.6 Not only does simulation training provide learning at the individual level, it has an integral part to play in systems testing. Every scenario holds the potential to learn and improve on the systems level7-8 and simulation can be a useful tool in the development of new standard operating procedures and policies needed to respond to the COVID-19 crisis.

Minimize the Gap Between Simulation and Reality: Provide Tools There are inherent difficulties with these simulations: we are still very far from being able to accurately simulate the complexity of nature around us. Additionally, the numerical methods that are commonly used 12

are notoriously difficult to fine-tune and control. Also, one of the limitations of most scenarios is that they are built in a linear fashion with or without branching. In reality, often decision making is performed in a cyclical fashion with nested conditional steps.9 Clinical scenario simulation training has been found to improve communication skills, the ability to work with other team members, and the ability to manage complex situations. It has been intensively investigated whether and to what extent certain measurable indicators are improved when the simulation with high fidelity models is incorporated into nursing education.

Numerous studies report that it contributes significantly to easier acquisition of knowledge (knowledge acquisition), to the improvement of psychomotor abilities (psychomotor abilities), to confidence (confidence), to the development of competencies (competence), to the interest for learning (motivation in learning), and even to satisfaction from the learning process itself.10 It also contributes significantly to the effectiveness of individuals and groups and therefore to patient safety.

At the end of the training, there should be an individual or group discussion on the script using the recorded audiovisual material and thus promoting reflective thinking and practice, where it will ultimately, effectively improve communication, skills and contribute to gaining confidence in nursing education.11 Program Evaluation and Review Technique Program Evaluation and Review Technique (PERT) is a popular tool for determining the appropriate decision-making time. The PERT, developed by Booz-Allen-Hamilton and the US Navy in collaboration with the Polaris missile program, is essentially a flow chart that predicts when events and activities must take place in order for a final event to occur. The creation of a PERT diagram for the development of the simulation technique with scenarios for the appropriate care of patients with COVID -19 in a public hospital is an auxiliary solution to a possible simulation program.

PERT is a very helpful tool when a group of people are working on a project. The schedule keeps everyone informed and problems are easily identified as soon as they occur. Evidence-based nursing practice incorporates the most valid knowledge available, the knowl-

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edge of specialists, the values and preferences of the individuals, families and communities served.12

REFERENCES

CONCLUSION

1. Geis GL, Pio B, Pendergrass TL, Moyer MR, Patterson MD. Simulation to assess the safety of new Simulation has great potential to help mitigate the healthcare teams and new facilities. Simul Healthc. negative effects of the COVID-19 crisis and poten2011; 6(3): 125–133. tially for future crisis situations. The examples and tips 2. Preston P, Lopez C, Corbett N. How to integrate provided in this paper can help simulation to harvest findings from simulation exercises to improve this potential in the interest of patients, relatives, the obstetrics care in the institution. Semin Perinatol. public, and—last but not least—healthcare profession2011; 35(2): 84–88. als.

3. McGaghie WC, Issenberg SB, Petrusa ER, Scalese RJ. Revisiting ‘A critical review of simulationBenefits of this high fidelity, in-situ, multidisciplinary based medical education research: 2003–2009’. simulation training have been demonstrated through Med Educ. 2016;50(10):986–991. increased situational awareness, purposeful behav4. McGaghie WC, Issenberg SB, Barsuk JH, Wayne ior and support, open communication and increased DB. A critical review of simulation-based mastery seeking of clarity and understanding. Additionally, learning with translational outcomes. Med Educ. increased teamwork and unity results in less shift-to2014; 48(4):375–385. shift division, creating more efficiency and account5. Ziv A, Wolpe PR, Small SD, Glick S. Simulationability of staff. Job satisfaction has also increased based medical education: an ethical imperative. resulting in decreased stress, turnover, and more transSimul Healthc. 2006; 1(4):252–256. parency. Future studies are needed to further analyze 6. Dieckmann P, Torgeirsen K, Qvindesland SA, benefits of training and correlation with quality and et.al. The use of simulation to prepare and improve safety measures. responses to infectious disease outbreaks like COVID-19: practical tips and resources from Norway, Test and training systems that use simulation can play Denmark, and the UK, Adv Simul (Lond). 2020; an important role in training new facilities. The core 5: 3. courses included early planning, effort allocation, 7. Hollnagel E. FRAM, the functional resonance flexibility to adapt to change, and planned integraanalysis method: modelling complex socio-technition with other training activities. A formal a priori cal systems. Farnham, Surrey; Burlington: Ashplan is required to address any issues identified during gate; 2012. p. 142. the process. In situ simulation can be used to identify 8. Patterson MD, Geis GL, Falcone RA, LeMasimportant latent hazards on a hospital, so that correcter T, Wears RL. In situ simulation: detection of tive actions can be iteratively tested and implemented safety threats and teamwork training in a high before the unit opens for patient care. In addition, risk emergency department. BMJ Qual Saf. 2013; incorporating SPs into the scenarios may allow a more 22(6):468–477.Kozmenko V, Wallenburg B. Simucomprehensive evaluation of the operational readiness lation in Healthcare. Journal of the Society for of a new hospital service line, by providing important Simulation in Healthcare. 2014; 9(6) p. 487. insights about the patient care experience.

9. Cant R. & Cooper S. Use of simulation-based learning in undergraduate nurse education: An umFinally, there are many models for improving decibrella systematic review. Nurse Education Today. sion making. The use of a systematic decision-making 2017; 49:63-71. model or a problem-solving model limits the trial and 10. Ηusebø S. & O’ Regan S. (2015). Reflective pracerror method or expert methods and increases the liketice and its role in simulation. Clinical Simulation lihood of making appropriate decisions. Management in Nursing. 11(8):368-375. science has created many tools that help people make 11. Anderson DJ & Shelton W. Clarify your financial better and more objective decisions, but everything is picture with staff management tools. Journal of subject to human error, and many do not take the huNursing Administration. 2005; 23-24.

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12. Bailey S. Decision making in acute care: A practical framework supporting the “best interests” principle. Nursing Ethics. 2006; 13(3), 284-291.

Article Information About the Authors: Mr. Stefanos Digonis is a Nurse with a postgraduate specialization in Nursing Internal Medicine. He works in one of the biggest Hospitals of Northern Greece in “Georgios Gennimatas”, Thessaloniki, in the Department of Internal Medicine Clinic. The six years of study mark a remarkable course for this important industry. At the end of the first two years the high level of knowledge and skills, inspired by the humanistic ideals of understanding, care and equality, was capable of adapting to a variety of scientific environments using critical analysis, problem solving and research evidence practice. The consequence of the above was the granting of a one-time scholarship in the second (2nd year) by National Scholarships Foundation due to an excellent performance 1st in his year. An award was also given for distinction in studies and ethics.

Participating in conferences as the first speaker contributed to the acquisition of knowledge, necessary information and experiences for information and better competence of fellow health professionals, giving at the same time the opportunity to present the work done with effort and time for academic needs. He is also the author of a number of articles of great scientific interest in distinguished international or domestic peer-reviewed journals. He is a nurse who focused on providing quality care and education to patients in matters of health and preventive care. Mr. Stefanos Digonis is married and has been living permanently for five years now in Central Macedonia in the city of Thessaloniki in Greece.

Mr. Paschalis Tasoudis is a Nurse with a postgraduate education in the field of teaching. Also, he is a graduate student specializing in Health Administration, Department of Business Administration, University of Macedonia, in Thessaloniki. Organization, experience, with development of professional consciousness and professional utilization of the knowledge acquired during the studies, in the integration in the productive system of the country are some of the elements obtained from the professional integration in the field through one of the leading private health care providers for the last 42 years (Euromedica General Clinic).

Mr. Tasoudis has been living permanently for the last 29 years in Central Macedonia in the city of Thessaloniki in Greece, where he was born, with the ultimate goal of providing the highest and most effective nursing care.

www.AAMCN.org Spring Managed Care Forum 2021 • Visit the AAMCN website at www.aamcn.org to register for the Virtual Spring Managed Care Forum Social Media • Members of AAMCN can join our new Facebook discussion group at www.facebook.com/ groups/AAMCN • LinkedIn 14

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Home Care Rapidly Adapts to Impacts of COVID-19, Shining a Light on Importance of Care at Home Lakelyn Hogan, MA, MBA, Gerontologist and Caregiver Advocate (1) & LaNita Knoke, RN, BS, CMCN, CRPF, Healthcare Strategist (1) 1. Home Instead Senior Care

Staying at home has been designated as one of the safest ways for people to reduce their exposure to COVID-19. This is especially true for the most vulnerable, including the older adult population. The home care industry has been working to keep aging adults safe and healthy at home for decades. However, home care services have often been overlooked by the health care system or confused with home health services. Home care is provided by trained professionals with customized plans of care to assist with a range of needs including personal care, medication administration and management, memory care support, and more. During this time, when home is the safest place to be, home care has been deemed an essential service and an important factor in keeping seniors out of the hospital and protected from exposure to COVID-19 and other infectious diseases.

While the goal of home care has remained the same during this pandemic, the way services are offered have been adapted. This article highlights the rapid response of a large home care organization, Home Instead Senior CareÂŽ and suggestions for best practice for the home care industry.

Long before COVID-19, Home Instead Senior Care had best practices in place for the health and safety of all stakeholders including older adults, professional CAREGiversSM, and office staff. These precautions were originally developed to reduce the spread of illness, especially during influenza season. This pandemic highlighted the need for Home Instead Senior Care to reinforce and build upon these best practices in the following areas.

Nation-Wide Support The Home Instead Senior Care Global Headquarters assembled a COVID-19 response team that shifted its focus entirely on the pandemic. This cross functional team worked to understand the everchanging information provided by the World Health Organization and Centers for Disease Control. They compiled this information and created helpful resources, which were effectively disseminated to local franchise offices. This allowed offices to focus on their team and client safety, along with the local health department guidelines. This taskforce identified a need for network exposure support and developed an exposure triage team. This team supported the network as they worked through their potential and confirmed exposures impacting their business, CAREGivers, clients, and clients’ families.

The exposure team also identified the need for mental health resources to support the network in their grief and loss.

Reinforced Training The ability of the Home Instead Senior Care network to reinforce employee training was important, and it was accomplished quickly. Education included standard precautions, hand washings, infectious disease control, and proper use of personal protective equipment (PPE). Verification of completed education from franchise offices ensured consistency across the network.

Adapted Local Operations Operational practices at the local franchise level were also adapted. While in most cases the essential home care services continued in the home, technology was utilized for additional operational efficiencies. Instead

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of in-person care consultations and quality assurance • Keep network informed on infection control procevisits, virtual interactions took place. Fortunately, dures and new potential viruses that could become virtual technology had already been deployed in some a threat clients’ homes and this was utilized as an alternative or ARTICLE INFORMATION enhancement to their current care.

Extended Family Caregiver Resources Home Instead Senior Care has always been dedicated to supporting family caregivers but noticed the added strain they were experiencing as a result of COVID-19. To provide information and support, Home Instead Senior Care created a COVID-19 resource page with articles to help family caregivers such as “5 Important Questions to Ask Seniors during Social Distancing” and “7 Ways to Keep Seniors Engaged during COVID-19.” A “Caregiving during COVID-19” Facebook Live Series was also held on topics to help caregivers navigate their role during this challenging time. Topics included social isolation, technology and caregiving, and dementia care.

About Home Instead Senior Care: Founded in 1994 in Omaha, Nebraska, the Home Instead Senior Care® franchise network provides personalized care, support, and education to enhance the lives of aging adults and their families. Today, the network is the world’s leading provider of in-home care services for seniors, with more than 1,100 independently owned and operated franchises that provide more than 80 million hours of care annually throughout the United States and 13 other countries. Home Instead Senior Care franchise owners partner with clients and their family members to help meet varied individual needs. www.HomeInstead.com Author Contact Information: Phone: 402.498.4466 Emails: lakelynhogan@homeinsteadinc.com & lanita.knoke@homeinsteadinc.com

Offered Professional Education There was also a need that Home Instead Senior Care saw for professional education during this time. In partnership with the American Society on Aging, a series of webinars were offered with free CE credit.

Topics included: • Technology and Caregiving • Loneliness & Aging: The Other Epidemic • Preparing for Loss: Death, Dying and Grieving As Home Instead Senior Care moved through the pandemic, key elements of the business were continually analyzed to improve upon best practices. The lessons learned from that analysis supported the changes made in the organization’s approach to caring for the nation’s older adults. The key elements of learning are included below: Critical Learnings for Home Care: • Assemble a cross functional situational task force for these types of circumstances • Embrace technology and utilize virtual communication with all stakeholders • Regularly update protection procedures, training, and practices • Continually monitor the necessary tools and materials for providing care in these types of circumstances 16

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Creating Possible For more than 30 years, Gilead has created breakthroughs once thought impossible for people living with life-threatening diseases. We are a leading biopharmaceutical company with a pioneering portfolio and ever-expanding pipeline of investigational medicines.

Our commitment goes well beyond science. We innovate with the goal of eliminating barriers and providing access to healthcare for people who need it most.

For more information, please visit www.gilead.com.

We are committed to a better, healthier world for everyone.

GILEAD and the GILEAD Logo are trademarks of Gilead Sciences, Inc., or its related companies. www.aamcn.org | Vol. 7, No. Š2020 Gilead Sciences, Inc. All rights reserved. UNBM0241 07/20

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Compassionate Care: The Missing Link in Clinical Integration Bonnie Zickgraf, BSN, RN, CMCN Given the intricacies of the human body, an impaired body system cannot exist for long without corrective interventions as we are divinely woven together for the purpose of internal and external communications.

History and Discussion Medicine, religion, and spirituality coexisted for centuries. Priests and shamans were our healers for every ailment known throughout different cultures.

The focus of these healers was on the body and the spirit. Hospitals eventually were founded by religious organizations and were based on the foundation and the art of compassion. Advances in medical science in the early 20th century, “eliminated humanistic and spiritual aspects” of care.6 Clinicians relied heavily on what machines displayed to them. Caseloads increased the need to improve efficiency and to meet the bottom line of profitability.

In recent years, clinical integration attempted to draw the focus of patient and family to the center of the hub of clinical care, surrounding the patient with primary care physicians, teams of specialists, and ancillary staff as needed to address many patient needs.

With the advent of managed care, overutilization of services became a focus with limitations and restrictions based on medical policy language. The physician lost control of patient care limiting their expertise based on benefit coverage, network contracts, and reimbursement rates. Systems that were meant to become highly efficient often became so at the sacrifice of patient compassion. There simply was no time left in a day to provide the very core of what most clinicians hoped to accomplish at the beginning of their careers: caring for another human being in a compassionate, heartfelt, and humanistic way.

Prior to his demise in November 2018 during my husband’s last inpatient hospitalization, a hospital case manager came into his room for 30 seconds and intro18

duced herself by first name and a quick smile. She laid a form on his bed with instructions to fill it out and someone would be by to pick it up later.

The form contained many pages and many questions for a case management assessment which could not be completed by this sickly man who was riddled with cancer as he laid in this hospital bed. No one was available to help him try to eat at mealtime. Nurse call buzzers to go to the bathroom were a moot point as no one ever came. The care that was meant to cure or help the patient actually caused more harm than good for both patient and family. Worse even still, patients go home to receive surprise billing and thousands of dollars of debt for services poorly or never provided.

The clinical care system is broken.

Holistic care is described in the Indian Journal of Palliative Care (2017) as “approaches and interventions that are meant to satisfy a patient’s physical, mental, emotional, and spiritual needs.”4 According to Puchalski in “The Role of Spirituality in Health Care” (2001), Victor Frankl, a psychiatrist who wrote of his experiences in a Nazi concentration camp, wrote, “Man is not destroyed by suffering; he is destroyed by suffering without meaning.”5 Our clinical teams are missing a critical piece. Either systems are flawed because computers can’t speak between a primary care physician’s office and the specialist’s office, or because no member of the team has sufficient time to be still long enough to ask the patient how they are actually doing or what can be done to help them spiritually.

The Concept of Compassion as Spirituality In the concept of spiritual or compassionate care, “compassion” means to “suffer with.”

Spiritual healers and spiritual healing rarely exist within the context of modern clinical care; however,

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spiritual matters should be a part of every clinical assessment for quality of care and economic reasons.

Spirituality issues come from the heart, not from a machine

Spirituality is not the same as religion; however, prayer is commonly used by many people in different situations. Most Americans prayed on September 11, 2001 (9/11) when the World Trade Center Towers burst into flames and fell to the ground with thousands of people inside as we watched on live TV. We pray as our infants and premature newborns are strapped to needles and heart monitors and oxygen tubes in order to survive. Emergency room trauma teams and surgical teams will pray for divine guidance when a patient’s life seems to be slipping away. Families pray as they wait in cold and impersonal waiting areas with the hope of receiving good news of a loved one’s status. First responders pray during motor vehicle crashes when digging someone out of a windshield or when finding a child or family pet who was not restrained with a seat belt, now found at the side of the road struggling to breathe, if at all.

A nursing friend of mine reported working in ICU when a family decided to discontinue life support for a patient. The family gathered around the patient’s bedside and the medical team disconnected all machines to end his life. When this occurred, the patient began to thrash around in the bed, fighting for one last breath. My friend (the nurse) reported it was difficult to watch. Then without any prompting, the wife simply put down the bedrail and crawled into bed with her husband, consoling him and holding him until he passed away. These are spiritual matters and affect our hearts and our souls deeply. All of us.

Recovery groups such as Alcoholics Anonymous were founded on a belief in a higher power. Lonely nursing home/rehab center patients wait endless hours for someone to come to say hello to them. Their prayers of hope lament, “Perhaps maybe tomorrow.” Soldiers grieve over the loss of their limbs and their comrades.

Mothers, fathers, and widows cry with prayers at the graveside of their daughters, sons, and husbands.

It seems that only at the end of life, prayers are offered as a standard course of spiritual care. Why do we wait so long? Human beings need healing to start from within our minds, our bodies, our hearts, and our souls, yet addressing matters of spirituality are postponed to our last breaths on earth.

Spirituality touches all types of health issues, diagnosis, and recovery settings. Have you ever had the flu and prayed that you would feel better because you were so sick? What about watching a child who is so ill that you, as a parent, have done everything you could possibly do to help them and your prayers seem like the last resort. Have you ever experienced a broken heart or a lost relationship, feeling like you stepped into the deepest pit possible and you would never crawl out? Our spirit can be broken, yet unaddressed as part of recovery.

Numbers Support the Outcomes Empirical evidence has confirmed for many years that spiritual practice reduces the length of stays and recovery time and impacts positive outcomes.

A November 2019 Gallup Poll indicated that 87% of Americans believe in God. In 2010, 83% said there is a God who answers prayers. 72% of Americans say religion is important.1 In my own personal experience as an RN working Med-Surg and Psychiatric units, the people who prayed the most with patients were the janitorial and cleaning staff. They were loved by the patients because (unlike time-strapped clinicians), they took the time to compassionately identify with a patient’s spiritual needs.

According to Puchalski C. M. (2001), “The Role of Spirituality in Health Care,” Proceedings (Baylor University. Medical Center)5 • American Pain Society study in hospitalized patients (1999) prayer was used as a method of pain management: • 66% more frequently than IV medications • 62% more frequently than pain injections • 61% more frequently than relaxation, touch, and massage • 80% of parents whose children died of cancer reported a year later of comfort and coping through religious belief (1983) • Heart transplant patients (1995) holding spiritual beliefs and religious activities

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• Improved physical functioning at 12-month follow-up visits • Had less anxiety and higher self-esteem than those that did not On Christmas Eve 1955, The Journal of the American Medical Association published an article by Henry Beecher, M.D. entitled “The Powerful Placebo.”

The doctor reported an average of 35% of patients benefited when told that the placebo or fake “drug” they were taking for pain, cough, drug-induced mood changes, headaches, seasickness, or the common cold resulted in cures or positive outcomes. (Pulchaski, C. M., 2001). This landmark study of the placebo effect “has led to conclusions that our beliefs are powerful and can influence our health outcomes.”5 Yet the gap in addressing patient needs for compassion and spirituality remains.

A 2019 article by Harrad, et al, indicates there is a lack of nursing education in spirituality and compassion as a topic in nurses’ training. Nurses report a lack of confidence or the inability to address such matters with their patients. There is good news from the world of medical education, though. Medical schools in the US that incorporate spirituality in physician training rose from 13% in 1994 to 90% in 2014.3 This is a solid improvement, but more is needed. Physicians reported current barriers to implementation as: • an unknown or unstated standard definition of spirituality • a lack of assessment guidelines • time limitations to complete patient assessments • determining which team member is best to perform the spiritual assessment Patient Assessment Tools Many assessment tools currently in use typically ask if any preferred religion exists and ends there. Even if “none” is designated by the patient, we can ask: • Do you have any spiritual needs we can assist you with today? Answers may surprise you!

• They may want to talk to clergy, or to you!

• Patients may request a copy of materials (Bible, Torah, Quran) • A patient may request for you to make a phone call to family on their behalf • “Hold my hand.” “Sit with me for a minute, please.”

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Please do not be afraid to ask the questions that support a quicker and more complete recovery. Quality patient engagement time now can result in faster recoveries and less frequent bedside or clinic visits because the patient feels more satisfied and is spiritually stronger and healthier.

Patient and Organizational Assessments Many tools have been developed to review organizational readiness as clinically integrated networks.

Accrediting organizations offer readiness tools. State regulatory agencies may offer basic requirements as well for the development, regulatory approval and oversight of integrated networks.

Organizations must have a clear mission, purpose, and goals based on holistic, patient and family-centered care. Individual and organizational assessment tools should customize the depth and breadth of deeper review tools focused on patient needs including spiritual issues and not just the needs of the organization. Compassion must be built back into our systems as a matter of policy, culture and quality if we expect to succeed in the world of health care.

Payer Reimbursements and Incentives Managed care payers incentivized clinicians for quality of performance, clinical outcomes, patient satisfaction rates, and cost-effectiveness. Clinicians heed this: manage the quality and the quantities will follow!

An article by Grim and Grim in 2019 indicated a review of faith-based substance abuse recovery programs and concluded that there are “130,000 congregation-based substance abuse recovery support programs in the USA . . . these faith-based volunteer support groups contribute up to $316.6 billion in savings to the US economy every year at no cost to taxpayers.”1 With overwhelming empirical and financial evidence supporting the benefit of providing compassionate, spiritual care to patients, why does this continue to be so lacking in our broken systems?

The American Medical Association Journal of Ethics published this statement in 2018: “The core element of the healing relationship is our ability to adequately

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Image Retrieved 1/20/20 from https://creativecommons.org/licenses/by/3.0. Unknown author.

address all the concerns of our patients and their families—psychosocial, spiritual, existential, and physical—and to work in partnership with experts in each of these domains. Anything less than this is both inadequate and unethical in meeting our professional obligation to our patients and their families.”6 Final Thoughts “Organizations that begin to successfully integrate humanistic medicine with evidence-based mind-body practices empower patients to become active partners in their treatment. Such integrative practice reduces harm, sustains ethical and legal professional standards, gives purposeful direction to therapeutic interventions, and enhances the efficacy of conventional treatment plans. It is the future of good medicine.”2 Art, yoga, music, pastoral care, acupuncture, etc. are not typically reimbursable as stand-alone health care benefits, however realizing the financial and clinical impacts, organizations should consider implementing as sliding scale self-pay programs or (better yet), build such services into per diem costs or as a bundled service similar to palliative or hospice services.

REFERENCES 1. Grim, B. J., & Grim, M. E. (2019). Belief, Behavior, and Belonging: How Faith is Indispensable in Preventing and Recovering from Substance Abuse.

Journal of religion and health, 58(5), 1713–1750. doi:10.1007/s10943-019-00876-w 2. Hall, M., Bifano, S. M., Leibel, L., Golding, L. S., & Tsai, S. L. (2018). The Elephant in the Room: The Need for Increased Integrative Therapies in Conventional Medical Settings. Children (Basel, Switzerland), 5(11), 154. doi:10.3390/children5110154 3. Harrad, R., Cosentino, C., Keasley, R., & Sulla, F. (2019). Spiritual care in nursing: an overview of the measures used to assess spiritual care provision and related factors amongst nurses. Acta bio-medica : Atenei Parmensis, 90(4-S), 44–55. doi:10.23750/abm.v90i4-S.8300 4. Jasemi, M., Valizadeh, L., Zamanzadeh, V., & Keogh, B. (2017). A Concept Analysis of Holistic Care by Hybrid Model. Indian journal of palliative care, 23(1), 71–80. doi:10.4103/0973-1075.197960 5. Puchalski C. M. (2001). The role of spirituality in health care. Proceedings (Baylor University. Medical Center), 14(4), 352–357. doi:10.1080/0899828 0.2001.11927788

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6. Puchalski, C. M., Sajja, A. (2018). Training physicians as healers. AMA jpornal of ethics, Illuminating the art of medicine. AMA J Ethics. 2018;20(7):E655-663. doi: 10.1001/amajethics.2018.655.

ARTICLE INFORMATION For Additional Reading: 1. Aghakhani, N., & Park, C. S. (2019). Spiritual well-being promotion for older adults: Implication for healthcare policy makers’ decision making on cost savings. Journal of education and health promotion, 8, 165. doi:10.4103/jehp. jehp_236_19 2. DeHaven, M. J., Hunter, I. B., Wilder, L., Walton, J. W., & Berry, J. (2004). Health programs in faith-based organizations: are they effective?. American journal of public health, 94(6), 1030–1036. doi:10.2105/ajph.94.6.1030 3. Gosfield, A., Reinertsen, J. (2003). Library: Clinical assessment tools. Retrieved 1/5/20 from https://www.uft-a.com/ CISAT/library/ 4. Nieuwsma, J. A., Fortune-Greeley, A. K., Jackson, G. L., Meador, K. G., Beckham, J. C., & Elbogen, E. B. (2014).

Pastoral care use among post-9/11 veterans who screen positive for mental health problems. Psychological services, 11(3), 300–308. doi:10.1037/a0037065 5. Piderman, K. M., Marek, D. V., Jenkins, S. M., Johnson, M. E., Buryska, J. F., Shanafelt, T. D., … Mueller, P. S. (2010).

Predicting patients’ expectations of hospital chaplains: a multisite survey. Mayo Clinic proceedings, 85(11), 1002–1010. doi:10.4065/mcp.2010.0168 6. Puchalski, C. M., Vitillo, R., Hull, S. K., & Reller, N. (2014). Improving the spiritual dimension of whole person care: reaching national and international consensus. Journal of palliative medicine, 17(6), 642–656. doi:10.1089/ jpm.2014.9427 7. Purcell, H. N., Whisenhunt, A., Cheng, J., Dimitriou, S., Young, L. R., & Grossoehme, D. H. (2015). “A remarkable experience of god, shaping us as a family”: parents’ use of faith following child’s rare disease diagnosis. Journal of health care chaplaincy, 21(1), 25–38. doi:10.1080/08854726 .2014.988525 About the author: Bonnie Zickgraf, BSN, RN, CMCN, is a recently retired Accreditation Compliance Reviewer, URAC, and a Pastoral Counselor and Minister of Care Community of Faith United Methodist Church. She serves on the Board of Directors, American Association Managed Care Nurses, and the National Quality Forum Technical Expert Panel, Opioid and Substance Use Disorder, 2019-2020.

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Congratulations to the Newly Certified Managed Care Nurses (CMCNs)!

Trellis E Adams, RN, BSN, MSHS, WCC, CMCN Jerren Agnew, RN, CMCN Josephine Alexander, RN, CMCN Kimberly Patricia Alexander, RN, CMCN Leonor Z Alvarado, RN, CMCN Mistie L Armstrong, LPN, CMCN Dawn R. Ballantini, LPN, CMCN Chelsea Ballard, LVN, CMCN Darlene Barron, RN, CPN, CMCN Marcia Bates, RN, BSN, CMCN Debra Bellitter, RN, CCM, CPHQ, CMCN Rolando M. Benavidez, RN, BSN, CMCN Sarah Bernard, RN, CMCN Maria Boyd, RN, CMCN David L. Brown, RN, CMCN Rhonda Burns, RN, CMCN Justito F Candari, Jr., CMCN Robin Carlson, RN, CMCN Stephanie Cassis, LPN, CMCN Norma J. Chapa, RN, CMCN Teneka R. Cherry-Fobb, LPN, CMCN Robin Christman, RN, CMCN Marites Cruz, RN, CMCN Bethany Cummings, RN, CMCN Theresa K Dallas, BSN, RN, CMCN Amanda L Davis, BSN, RN, CMCN Rachel Davis, MSW, RSW, CMCN Allison M Dawson, LCSW, CMCP Misty J Deal, RN, CMCN Randy Dellinger, RN, CMCN Matthew R Di Micelli, RN, CMCN Jessica Dickinson, RN, CMCN Jenny Dixon, MSW, CMCP JoAnn M. Dunn, RN, CMCN Sonya Dupre, LPN, CMCN Deborah Faucett, RN, CMCN Cynthia J. Fischer, RN, CMCN Charmaine Flotildes, RN, CMCN Shauna Forbes, RN, CMCN Heidi Fuernstahl, RN, CMCN Celina H. Garza, RN, CMCN Chelsea Gaudet, LPN, CMCN Nathan Gillin, RN, CMCN Sherrie-Anne Gilmore, RN, CMCN

Shirlene Joyce Gines, BSN, RN, CMCN Matthew Green, RN, CMCN Katrina C. Griffin, RN, CMCN Marla K Griffith, RN, CMCN Mayolin Guerra, RN, CMCN Stephanie R Gusmao, LPN, CMCN Kelli Hantle, BSN, RN, CMCN Barbara Harris, RN, CMCN Cheryl Hebert, RN, CMCN Lucy Hensley, RN, CMCN Michael P Herbert, MSN, RN, CNL, CMCN Tiffany L Hinkle, BSN, RN, CMCN Carly Houzenga, RN, CMCN Antonia Ibarra, RN, CMCN Melissa D. Johnson, LPN, CMCN Deborah Jones, RN, CMCN Patricia Diana Kania, RN, CCM, CDP, BSN, CMCN Jessica Kayrouz, RN, CMCN Bakary Kinteh, MSN, MBA, RN, CMCN Jody A Latimer, RN, CMCN April Lavergne Hollinger, RN, CMCN Laura Litkea, RN, CMCN Leslie D Lockwood, LVN, LPN, CMCN Deborah Lohman, RN, CMCN Sharmarion N Lopes, RN, CMCN Wendy Machado, RN, BSN Sarah Mahaffey, LPN, CMCN Diane Mangona, LVN, CMCN Eileen Manuel, RN, CMCN Nancy Marini, RN, MA, CAPA HN-BC, CMCN Ashly Mayhon, RN, CMCN Preciousness McCorvey, LPN, CMCN Monya McKnight, LVN, CMCN Tina Meeks, APRN, CMCN Rebecca Meisenhelder, RN, CMCN Marsha L. Merrell, RN, CMCN Marjorie E. Miles, LPN, CMCN Randoshia M. Miller, RN, MS, BSN, CMCN Tiffany D. Minton, RN, CCM, CMCN Maggie D Moss, RN, CMCN Sandra L Munson, RN, CMCN Marjorie Napalit, RN, CMCN Ariana Navarro, LVN, CMCN Stephanie L Novotny, RN, BSN, CMCN

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Mary Ogden, RN, CMCN Kathleen Oglesby, RN, CMCN Chloe Ovinsky, RN, CMCN Wendy Jo Peter, RN, BSN, CMCN Julie Pizzolato, LPN, CMCN Nancy Pollard, RN, CMCN Kendra Pomerenke, RN, BSN, CMCN Victoria Pompey-Encalade, RN, CMCN Joy Posey, RN, CMCN Ellen Rafer, RN, BSN, CCM, CMCN Amy Ramirez, RN, CMCN Amber Ratliff, RN, CMCN Debra D Reiland, RN, CMCN Jennifer Rembold, RN, CMCN Karen E Roberts, RN, BSN, CCM, CMCN Regina H. Roberts, RN, BSN, CCM, CMCN Bridget Roberts-Taylor, LPN, CMCN Jennifer Rodriguez, RN, CMCN Rebecca Rooker, LPN, CMCN Peggy Rosik, RN, CMCN Jacqueline R Sadler, LPN, CMCN Circee Danise Saintilmond, RN, CMCN Tosca Camille Samson, LVN, CMCN Cindy Schmidt, RN, CMCN Amanda J Schneider, RN, BSN, CMCN Kristin Schoenike, RN, BSN, CMCN Eileen Scott, RN, BSN, CMCN Lisa M Sheffield-Howell, RN, CMCN Zahid Siddique, RN, CMCN Jossett Smith, RN, CMCN Rhea Sobremesana, RN, CMCN Gary Solmerin, RN, CMCN Kymberly Spady-Grove, DHSc, BCD, CPhT, LCSW, CMCP Angela Stacy, RN, CMCN Tamsen Staniford, RN, CMCN Megan Stillwell, RN, CMCN Joann Louise Storey, RN, CMCN Angela Suarez, RN, BSN, MS, CMCN Masako Suzuki, MSW, LSW, CCM, CMCP Justine Tallon-Satink, RN, CMCN Samantha Tapia, LPN, CMCN Natalie Treigle, RN, CMCN Monique Triplett, LPN, CMCN Kyla S U’Ren, RN, CMCN Carmen Vasquez, RN, CMCN Shanda Watson, RN, CMCN Sharlene Waylon, RN, CMCN Storie Weissman, RN, CMCN 24

Amy Westgate-Watts, RN, CMCN Tiaka Williams, RN, CMCN Amy Wilson, RN, CMCN Melissa Worrell, LVN, CMCN Mary E Yancy, RN, CMCN Danielle Zander, RN, CMCN

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