Magnet Recognition Program® Request for Additional Documentation
Homestead Hospital
Homestead, FL
MGN20140102
TL9EO Nurse leaders (exclusive of the CNO) use input from clinical nurses to influence change in the organization; Choose two of the three below (examples must be different from those provided in TL8.
TL9EOb: Provide one example, with supporting evidence, of a change in the patient experience that was influenced by the clinical nurses' communication with a nurse leader. Supporting evidence must be submitted in the form of a graph with a data table that clearly displays the data.
The narrative stated that the desired change in patient experience (outcome) was, “to decrease patients’ anxiety during CTA procedures through comfort interventions”; however, the narrative indicated that the measure identified was the “percentage of CTA patients using beta-blockers 15mg and higher prior to the procedure”.
Anxiety-reducing comfort interventions for this patient population were begun in February 2014; however, pre- and post-intervention data to demonstrate decrease in patient anxiety during CTA procedures were not provided.
Please provide the missing data to demonstrate the change in the patient experience that resulted from the intervention described in the narrative. If the data are not available, a new example may be provided.
______________________________________________________________________
A new example is provided below.
Example 2 – Change in Patient Experience
NAME OF INITIATIVE
Baptist Health Follow-up Care: A Nurse Practitioner-Managed Chronic Disease Transitional Clinic
BACKGROUND/PROBLEM
Homestead Hospital, a part of Baptist Health South Florida (BHSF), is the only acute-care hospital in the Homestead and Florida City patient service areas. It resides in a traditionally rural and underserved community in South Miami-Dade. According to the 2010 U.S. Census, half of the residents in the Homestead Hospital’s service area were foreign-born, with 75% of Latin or Hispanic descent, and 71% reporting a language other than English spoken at home. The average household income was $46,278, which was below the average Miami-Dade County household income of $61,035. In fact, 23% of residents in Homestead Hospital’s patient service area lived with incomes less than the federal poverty level.
Research has shown that people with lower socioeconomic status often turn to the Emergency Departments (ED) for primary healthcare. This phenomenon was evident among Homestead Hospital’s patients. For example, in 2011, 36,800 (71%) of adult patients seen in Homestead Hospital’s ED were for levels 1 and 2 conditions (diagnoses that could have been treated in a physician’s office or clinic). This demonstrated that they were turning to the ED for primary care more often than for emergency care. The community was also beset with a huge proportion of uninsured adults with chronic diseases. In 2010, heart disease was the leading cause of death in Homestead Hospital’s service area, followed by chronic obstructive pulmonary disease (COPD) and diabetes mellitus (DM). The dearth of primary care physicians in the community; the 6-week waiting list in the local free clinics; and the lack of knowledge with case management and care navigation after discharge among these patients lent to high readmission rates. From October to December 2011, Homestead Hospital’s DM readmission was 21.88% (all payers).
GOAL STATEMENT(S)
Homestead Hospital’s goal was to improve patients’ experience by decreasing DM readmission rates.
DESCRIPTION OF THE INTERVENTION/INITIATIVE/ACTIVITY (IES)
Responding to the needs of the community, Homestead Hospital, with the support of BHSF, opened a transitional primary care clinic in the community. Assistant Vice Presidents (AVP) Ann Marie Allen, RN and Ana Cabrera, ARNP designed this unique care delivery model while going through the Nurse Executive Academy (NEA). They determined that a Nurse Practitioner (NP) would be the most efficient and cost-effective health professional to manage the center and offer patients personalized care. The NP’s clinical expertise and advanced training were fitting for such a role. The NP would be operating under a supervising physician protocol (with no physician on-site) and responsible for recruitment; day-to-day office operations; and care plan tailored to the patient’s work schedule and lifestyle. The NP would also be able to bill directly for 85% of Medicare fees. Another important provision of the model was incorporating intensive case management by a social worker; a financial representative; and a patient educator.
The primary function of the clinic was to see patients who have been discharged from Homestead Hospital with chronic disease(s) such as DM and did not have medical insurance. The clinic also followed-up patients who were not able to see a primary care provider within 2 days of discharge from the hospital. The Baptist Health Follow-up Care opened its doors on April 2012. Allen and Cabrera hired Nurse Practitioner Adaeze “Chika” Ohaeto, ARNP to run the clinic.
The initial referral process was as follows.
- Once patients were admitted to the hospital, the inpatient social worker assessed the patients’ discharge needs.
- Social workers evaluated patients with chronic diseases (regardless of financial status) on their follow-up discharge needs (how and number of visits needed).
- Attending physicians made all referrals to the clinic.
As a truly NP-managed clinic, Ohaeto spent more than half of her time seeing patients while managing the administrative functions of the clinic. In this case, Ohaeto fulfilled the definition of a clinical nurse. Ohaeto’s clinical nurse role at the clinic was to act as the patient’s primary care provider until the patient was transitioned into a medical home. During the initial visit, the patient financial representative met with patients regarding completion of the patient financial assistance application. Ohaeto then met with all patients and developed individualized care plans. She performed medication reconciliation on each patient. She also ascertained whether the patients were able to afford the medications prescribed from the hospital. In some cases, she made affordable substitutions during the first visit. Generally, the maximum time a patient could be seen at the clinic was 6 months. However, each individual was treated differently depending on identified needs. For example, some patients may need to be transitioned earlier because they needed specialty care. On the other hand, patients who required extensive education usually stayed longer. There were also cases in which patients stays were extended beyond 6 months because they needed time and assistance in completing the documents required for transition to a community clinic. Patients who were kept longer at the clinic were more likely to have a better experience and a better understanding regarding self-management of their disease process.
Clinical Nurse Communication with Nurse Leader
Even though the clinic was making some progress in decreasing DM and other chronic disease readmission rates within its first 6 months of operation, Ohaeto noted that their referrals numbers were relatively low. Many chronic disease patients were still experiencing the “revolving door” syndrome of being readmitted to the hospital within 30 days. Consequently, she reviewed the referral process and determined it could be improved to better meet the community needs. Ohaeto (clinical nurse) met one-on-one with Allen (nurse leader) and discussed ways to increase referrals. She suggested to Allen giving the nurses at Homestead Hospital the autonomy to refer patients to the clinic without a physician’s order.
Based on the above communication between the clinical nurse and the nurse leader, Allen made changes to the referral process that impacted the patient experience post-discharge. This took effect in February 2013. Under the new process, clinical nurses and social workers could independently make referrals to the Baptist Health Follow-up Care without needing physicians’ order. It could be done via email; completing the referral form; or calling the clinic directly. Once a referral was received, the clinic’s social worker would make rounds at the hospital to meet with the patients/families and speak to them about the clinic. This introductory visit was aimed at reducing patients’ anxiety going into a new facility for post-discharge follow-up. It was also to set-up a follow-up discharge appointment. As a result of the process change, the clinic received 274 new referrals from January to May 2013.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Ann Marie Allen, MSN, PHD(c), RN, NEA-BC |
Director then; |
Nursing Administration Homestead Hospital |
Nurse Leader |
Adaeze “Chika” Ohaeto, DNP, ARNP, ACNP-BC |
NP for Baptist Health Follow-up Care Clinic |
Baptist Health Follow-up Care |
Clinical Nurse; Saw patients and managed the clinic |
Carla Paulina, MSW |
Social Worker |
Baptist Health Follow-up Care |
Assisted with socioeconomic issues and pre-/post-hospital interviews |
Vilma LaPorte, MSW |
Social Worker |
Baptist Health Follow-up Care |
Assisted with socioeconomic issues and pre-/post hospital interviews |
Martha Dana, BSN, RN, CDE |
Diabetic Educator |
Baptist Health Follow-up Care |
Educated patients on disease process, diet and medication. |
Michelle Portal |
Medical Assistant |
Baptist Health Follow-up Care |
Performed vital signs and assisted NP. |
Ricardo Santiago |
Patient Financial Representative |
Baptist Health Follow-up Care |
Assisted patients with insurance and other financial-related issues. |
OUTCOMES
Since opening the clinic, Ohaeto and her team successfully transitioned 80% of patients seen at the clinic to a permanent medical home. In an effort to continuously look for ways of improving patient experience, Homestead Hospital expanded the diagnoses seen at the clinic. In June 2015, Baptist Health Follow-up Care started accepting referrals for other conditions such as pneumonia, upper respiratory infection, urinary tract infection, backache/headache, simple wound checks and INR testing.
Exhibit TL9EOba: Homestead Hospital DM Readmission Rate
Analysis: Homestead Hospital achieved its goal of reducing DM readmission rate (patient experience) as evidenced by 3 consecutive data points below the baseline post-intervention.
Summary Attachments/Hyperlinks/Evidences
Exhibit TL9EOba: Homestead Hospital DM Readmission Rate