Nurse Practitioner Care

Scope: During this period Dr. Parackal has worked as 8 hours day tour of duty as a float provider. Dr. Parackal worked at Tulsa Outpatient Clinic as an Advanced Practice Registered Nurse for past 6 and half years. She was worked as a Primary Care Provider for Green Team 3 for almost 3 and half years. She also worked as an intake provider, employee health provider, substitute for PCP’s. Currently, she accepted the position as a Primary Care Provider for Red 4 to provide timely comprehensive care to veterans and thereby increases both patient and employee satisfaction scores. This also helps with constancy of patient care for Red team 4 panel patients.

1. Practice: Facilitates interdisciplinary care of complex patients, treat and resolve unusual or unique patient care problems or situations which require analytical, interpretive and constructive thinking; demonstrated by the ability to provide to provide leadership in application of the nursing process to patient care and organizational processes, improving outcomes at the program or service level.

Dr. Parackal has continued to work in improving access and care across the facility. This is evidenced by her active role as a float provider. As a float provider, she takes care of walk-in patients at TOPC. When a provider call-in Sick or absent, she covers the team for that whole day. This help to reduce the cancellation and re-scheduling of patients at the clinic. Dr. Parackal’s ability to work as a float provider as well as PCP for team, demonstrates collaborative leadership in establishing role of APRN. Her contributions to this area of practice has a positively impacted patient care and formed a cohesiveness of staff at this Outpatient clinic. Dr. Parackal is always keen and makes recommendation for change and acts of those recommendation (Example: Cognitive Behavioral therapy for Chronic Low Back Pain and reducing opioid pain medication). Recently, Dr. Parackal took a position as Primary Care Provider for Red team 4 and managing a panel of 950+ patients. This showed her dedication to provide a comprehensive care to veterans in a timely manner. During short period, as PCP for Red Team 4, she could reduce opioid prescriptions for the team as well as provide comprehensive care to team patients. This is evidenced by reduced HBA1c as well as BP parameters. She managed to complete day to day patients view alerts. Dr. Parackal has an excellent ability to do consult for patients with complicated disease process and these patients require specialty care. She is very efficient to manage Non- VA consult in timely manner such as ordering Non-VA consult, additional consults or investigational studies for follow up care. This helps to provide care timely efficient manner and prevents delay in care. This improved both SHEP score and Medalian scores. She has improved care of patients at TOPC by completing daily view alerts, increasing patients access, performing huddles and reviewing the patient’s appointments. Her medical decision in Primary care is based on evidence-based protocols, in conjunction with interdisciplinary collaboration to deliver care to complex patients. Dr. Parackal received lots of complementary letters from her patients for providing an outstanding comprehensive care to the patients.

As result of efficient care, the opioid prescription for Red 4 panel is decreased by the 10%, and total number of prescription decreased by 15%. This help to save lots of money to Tulsa Outpatient primary care Clinic.

In last 5 months, Dr. Parackal teach Tai-chi from 4 to 5 pm as a volunteer to TOPC to help with MOVE programs and plays as an active role in awareness and prevention of obesity among the veterans. This helps to reduce obesity in 5% of the MOVE consults patients.

2. Ethics: Dr. Parackal acts as a role model of expert and ethical leadership: analyzes ethical care issues, applying appropriate theoretical principles to ensure appropriate application of institutional policy: maintains confidentiality of all patient, family, and staff information which includes verbal, electronic and printed communications.

Dr. Parackal serves as a patient advocate for the veteran’s safety and rights. She practices in a nonjudgmental, non-discriminatory manner that helps to provide patients with access to voice their concerns and frustrations. She recognizes the importance of ethical issues, follows the HIPPA guidelines, and ensures the computer is logged off after the use. Dr. Parackal works closely with social worker and palliative care teams to ensure that veteran’s needs are addressed in timely manner, especially patients with terminal illness. Dr. Parackal always make sure who is accompanying the patient and ask permission from the patient before initiating a conversation. She demonstrates awareness of professional ethics, policies, and procedures regarding ethical issues. Dr. Parackal reports illegal, unethical, or impaired practices. She maintains a high level of integrity and can be counted upon difficult situation for her profession. Most of time, when there is a difficult angry patient, Dr. Parackal is called to see that patient and patient usually leave the medical facility with smile and felt that his voice and problems were heard and taken care off. She also maintains professional boundaries with co-workers, patients, and family members. Dr. Parackal adheres to the VA guidelines for coding encounters to accurately capture the care provided at each patient encounter.

As results about 30% of the patients in her panel have the life sustaining order in the CPRS. 100% of patients receives opioid medication have the pain agreement contract, Prescription monitoring program (PMP) check as well as periodic urine drug screen in CPRS.

3. Resource Utilization: Identifies and analyzes potential/actual problems involving resources for patient care issues to evaluate appropriate cost-effective options available in selection of course of action/care which will result in the most favorable patient and/ or organizational outcomes.

Dr. Parackal provides patients centered care in a safe, efficient, and cost-effective manner. She reviews Non-VA care reports, and pervious investigations studies and labs, and reports from others VA (for transfer patients) to avoid repetition of the investigational studies and cost. Dr. Parackal always orders the follow up labs to avoid unnecessary labs and x-rays during follow up visits. She always gives card and remained the patient to make follow up appointments before patient leaves the clinic. Dr. Parackal always go over the medication list, educate the patients about the medication, and discontinue the medications that patients not taking. She always uses RN visits for patients whose chronic disease condition’s medication changed (HTN or DM). Dr. Parackal always gives a written information about the follow up appointment for labs only and PCP visit. This helps to avoid confusion among the patient about their visit. Dr. Parackal also do telephone visit to discuss about labs, investigational studies, and follow up care. The proper use of telephone visits and RN clinic helps to increase patients open access to her clinic. Dr. Parackal never called in sick in her 6 and half years of working in the VA. She is always willing to work during holidays or weekends when scheduled provider has inconvenience to work. Sometimes if the patient comes for problem focused visits, and he is due to for annual comprehensive visit, Dr. Parackal completes annual visits on that visit to make sure VA facility will get the VERA money for that patient in a timely manner. She is always willing to demonstrates new skills, techniques, and use of technological advances with her peers and other staff members to help make their jobs easier. Dr. Parackal always order facility MRI’s and CT scans for the patient to reduce the cost as well as for timely follow up care.

As result 100% of follow up patients had follow up labs ordered, and 90% patient had made follow up appointments before leaving the clinic. This again increases patient’s satisfaction. Dr. Parackal has access to same day appoints now without jeopardizing the clinic schedule.

PRPFESSIONAL DEVELOPMENT

1. Performance: Develops evidence-based protocols and implements same and evaluates their effectiveness to enhance patient care quality, all in collaboration with the Interdisciplinary team: Functions as a leader by leading project teams, task forces, research projects and regular committee meetings which contribute directly to the improvement of patient care.

Dr. Parackal strives to perform at the highest level of her education. She has a excellent leadership skills and serves as a resource person to identify and develop policies and procedures to support improvement of performance. She is always willing to orient new physicians, nurse practitioners, and physician assistants. She always acts as a mentor for new comers till they become comfortable with their job. She also plays an active role as preceptor for APRNs from various universities. Dr. Parackal always very helpful and willing to work with any teams in the primary care Clinic. She always willing to cover for Physicians when they are sick or taking emergency leave. She keeps her supervisors informed the issues within the Outpatient clinic. Dr. Parackal maintains education current to provide comprehensive care based on new evidence-based practice and guidelines. She attends the education conferences and reviews scholarly articles and journals on regular basis to maintain her knowledge of current technique, trends, and professional issues. Dr. Parackal received compliments from follow co-workers for excellent patient care provided to the patient when they are on leave. She also works as a response provider taking care of emergency medical conditions of patients.

Dr. Parackal also increases patient access by doing telephone clinic visit. She educated other providers about telephone and improve the access to clinic. Overall, 25 % increase in telephone visits in Red 4 team clinic and about 15 % increase telephone visits in TOPC itself.

In last 6 months, Dr. Parackal oriented 3 new primary care providers at TOPC and precepted one APRN student.

2. Education: Provides basic and advanced nursing and interdisciplinary education and training for new APRNs and staff nurses as well as advanced training and development in management of complex patient care issues; facilitates inter-professional education as well as patient and family education at the patient and program level Maintains clinical competencies through continuous study, attending and presenting in-services, participation in seminars and workshops, with on-going demonstration of knowledge/skills necessary for effective care of patients within their specialty.

Dr. Parackal received a Doctorate in Nursing Practice from Missouri State University in 2016. She also received an academic excellence certificate from Missouri State University. She completed OOORAM training at Muskogee VA Hospital in 2017. Mrs. Parackal completed the Nurse practitioner program from the University of Oklahoma and holds an American Academy of Nurse Practitioner license since 2011. She has also showed keen interest in education by attending the Women VA conference in Florida, the American Nurse Practitioner Conferences, and the Association of Oklahoma Nurse Practitioner conferences. She completed all mandatory education in a timely manner in TMS. She is very active in education other staff and often call to assist other providers with orders and consults. She holds current certification in BLS and ACLS.

As a preceptor, Dr. Parackal mentored many students from different universities including Maryville University, the University of South Alabama, and Graceland University.

Collaboration

1.Collegality: Provides consultation as well as direct services for patients with complex disease, makes significant, sustained contributions to the nursing profession which may include publications, member ship on task forces, intra/external committees, consulting in areas of expertise, use of creative approaches to enhance productivity of patients care.

Dr. Parackal has positive communication skills and excellent team work that promote co-operation and team work with internal and external interdisciplinary teams. She accepts constructive feedback and clinical judgement from supervisor and colleagues. She volunteered to work in emergency when additional staff were urgently needed, volunteered to work on the overdue consults task force when urgently needed. Dr. Parackal is active in serving as mentor, preceptor and educator in the Outpatient Clinic. She volunteered one-hour per week after her regular tour of duty to teach Tai-Chi as part of MOVE program. She volunteers for the assignments above and beyond her regular duties to ensure that VA provides comprehensive care to veterans. She helps to update policies such as review of Non-VA report. Dr. Parackal was suggested if the providers write the summary of Non-VA medical report in the CPRS that will be very beneficial to follow up care for the patient during post hospital visit and to obtain the information easily. This is a practice continuing at TOPC by many PCPs. She educates other clinical staff such MSAs and nurses about the handling of Non-VA medical report which save lots of time for the providers as well as clerical staffs. This also helps to complete weekly review of Non-VA report, provide follow up care as well as order any additional investigational studies. This in turn helps to improve patient’s satisfaction and provide cost effective comprehensive care.

Dr. Parackal also received many complements from Muskogee Radiologist for ordering proper timely investigational studies.

2.Collaboration: Work collaboratively with multidisciplinary teams to address complex patient care needs; Communicates efficiently and uses listening skills with patients and others to maximize positive outcomes

Dr. Parackal demonstrates positive communication skills by communication with all Primary Care team members to promote cooperation among staff members. She has collaborated with other disciplines, staff, and students in providing optimal care for patients. She shares information about patients to other services such as social workers, and mental health providers as needed to provide comprehensive care to veterans. Dr. Parackal coordinates and makes sure that the patient’s needs are effectively addressed and communicates with multidisciplinary team to provide cost effective care. Dr. Parackal has developed professional relationship with other team members with her ability to collaborate and communicate efficiently with others. She responds to e- mails and inquiries from team members in timely manner. Dr. Parackal provides leadership in ensuring that the workload is completed in a timely manner by striving to complete all daily tasks such view alerts, consultation, telephone calls and e- mails. Dr. Parackal’s DNP research is an example of leadership and collaboration, she had to communicate with different interdisciplinary teams and talk with pain clinic managers about the research study, implementation of research, and data collection. During research, she could make therapeutic relationship with various other departments, such as the Research and Development committees, ISO officers, and hospital administrators.

SCIENTIFIC INQUIRY

1.Quality of care: Assesses plans, implements, and evaluates the total health care of a specialized patient population and implements improvements in health care delivery systems for the population they serve; analyzes and upgrades patient care through quality improvement activities, such as fulfilling national directives, EPRP reviews, and in chart reviews of documented care.

Dr. Parackal uses her experience as a nurse practitioner to provide effective comprehensive care to Veterans and their family members. She role model’s advocacy and provision to provide superior patient care through clinical expertise as evidenced by maintaining high standards of patient care, accountable for the care provided, and sharing new evidence-based knowledge among the PCP’s and other health care providers. Dr. Parackal attends conference and journal club meetings to enhance her knowledge to provide high quality of care. Dr. Parackal applies her knowledge of the quality improvement process gleaned from this and other schedules meeting as she is taking care of complex patient with pain or dermatology problems (San Echo consults and Tele dermatoly consult). Dr. Parackal provides high quality care which demonstrated by no action required for previous days job. Dr. Parackal demonstrated Primary Care quality care by maintain outstanding performance and satisfaction score on her annual performance evaluation. As mentioned earlier, due to her high quality of care, she received many complements and letters from the patient. Recently, she become one of the final contest for Daisy Award.

1.Research: Collaborates with others in research activities to improve care; disseminated the research finding to improve the quality of care.

Mrs. Parackal just completed her VA based research about Cognitive Behavior Therapy (CBT) for patients with Chronic Low Back Pain and found that CBT is effective for patients with Chronic Low Back Pain. Dr. Parackal had presented research outcomes to PCP meeting. Currently, CBT is used as one of the non-pharmacology method to manage chronic back pain and reduced opioid prescription for Veterans. Dr. Parackal research article was selected for Editor’s best choice by Journal of Nurse Practitioners.

Currently, 75% of the Primary Care Providers refer the patients with Chronic Low Back Pain (CLBP)for Cognitive Behavior Therapy(CBT) at TOPC. This helps to reduce opioid pain medication prescription as well as use CBT as non- pharmacological method for treating CLBP.

1.Goals: Mrs. Parackal’ s personal goal is to provide excellent, comprehensive care for the veterans. Being an excellent team member in providing comprehensive care to Veterans based on the core values of the VA, integrity, commitment, advocacy, respect, and excellence (I CARE) to provide an excellent quality of patient care. As a VA employee, I follow the mission of the VA and fulfills President Lincoln’s promise “To care for him who shall have borne the battle, and for his widow, and his orphan” by serving and honoring the men and women who are America’s Veterans. By being a member of the VA’s outpatient clinic, I will give priority to veterans with the first focus of care and provide high quality and compassionate care for all veterans.

2.To obtain a Family Nurse Practitioner certification in next year.

3.To do research in TOPC about comparison of patient’s Chronic disease conditions managed by a Physician and a Nurse Practitioner in VA Outpatient Clinic.

I hereby attaching my research protocol:

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