EP5 Nurses are involved in interprofessional collaborative practice within the care delivery system to ensure care coordination and continuity of care.
Provide two examples, with supporting evidence, of nurses’ involvement in interprofessional collaborative practice that ensures care coordination and continuity of patient care.
Example 1
NAME OF INITIATIVE
Wound Care Coordination of a Patient with Special Needs
BACKGROUND AND PURPOSE
In Homestead, Florida, about 29% of the population lives below the poverty line, and the median income is $38,724 - almost $10,000 below the Florida average. Homestead Hospital’s Emergency Department (ED) sees over 90,000 patients a year and is the third busiest in Miami-Dade County. The majority of patients seen in the ED and subsequently admitted are self pay, Medicaid or Medicare recipients. The mission of Baptist Health South Florida (BHSF) is to improve the health and well being of individuals and to promote the sanctity and preservation of life in the communities served. It is dedicated to providing high quality, cost effective, and compassionate healthcare services to all, regardless of religion, creed, race or national origin, including, as permitted by its resources, charity care to those in need.
Homestead Hospital espouses a Nursing Professional Practice Model consisting of Care Delivery System, Communication, Clinical Practice, Professional Development and Collaboration. At the heart of the PPM are the patient and family. The resulting process is that clinical nurses partner, communicate, and collaborate with the patient and family, and the interprofessional team in formulating the plan of care.
Homestead Hospital's care delivery system is a component of the PPM. It emphasizes the role of clinical nurses as primary caregivers. It delineates the nurses’ authority and accountability for clinical decision-making and outcomes of care provided based on regulatory standards such as the Nurse Practice Act and utilization of the nursing process. It further describes the resources available to the nursing staff and the importance of partnerships, shared decision-making and communication in the delivery of care.
Homestead Hospital’s nursing team adopted patient-and family-centered care and comfort theory as the overarching theoretical frameworks in the care delivery system. Patient- and family-centered care is an approach to the planning, delivery, and evaluation of healthcare which is a mutually beneficial partnership between patients, patients' families, caregivers and healthcare providers (http://www.ipfcc.org/faq.html). Its premise is based on true partnerships with patients and families. This entails involving them in care decisions and obtaining the benefits of their help and insights in the plan of care to achieve better patient/family and organizational outcomes with staff satisfaction. On the other hand, the Comfort theory, developed by Dr. Katharine Kolcaba, RN, has its major underpinning in the holistic comfort needs that human beings require. She advocates that it is an important mission for the healthcare team to meet these comfort needs. When patients and families experience enhanced comfort, they engage in health-seeking behaviors that lead to better outcomes and institutional integrity. Homestead Hospital nurses have fully embraced these concepts because of the unique opportunity through interactions with patients and families in partnering with and meeting their holistic comfort needs.
The following narrative describes how nurses are involved in interprofessional collaborative practice that ensured coordination and continuity of care of a complicated wound care patient.
In August 2013, a 41 year old, unfunded, male, Hispanic immigrant was admitted through the ED. He spoke very little English and had no immediate family in the US. His support system consisted only of close friends. The patient presented with a total body rash and multiple abscesses in his lower extremities due to an allergic reaction to eating mangoes. He was treated with intravenous (IV) antibiotics and admitted to a medical-surgical floor. Over the next 5 days, his condition deteriorated and he was transferred to the Intensive Care Unit (ICU). He developed rhabdomyolysis and multiple sites of severe pyomyositis, a purulent infection of skeletal muscle that arises from hematogenous spread, usually with abscess formation. Consequently, he developed respiratory insufficiency, became ventilator dependent and had a tracheostomy. He became physically debilitated and needed physical therapy to regain strength.
He underwent several extensive open debridements down to the fascia of all 4 extremities, gluteal-perineal area, chest wall and axilla visiting the Operating Room (OR) 12 different times. The resulting open wounds required intensive wound care and wound vac treatments, a negative pressure wound therapy system, to close his wounds. While in ICU, he required 1:1 nursing with wound care taking up to 8 hours to complete. He remained in ICU for 4 weeks and was subsequently transferred to 3 South.
The floor he was transferred to, 3 South is a 27 bed medical-surgical telemetry unit, specializing in orthopedics. The nurse-to-patient ratio is 5:1 and the clinical partner-to-patient ratio is 8:1. They adopted team nursing as their care delivery system. The floor has a mini-wound care team, consisting of RNs who have undergone the National Database for Nursing Sensitive Quality Indicators (NDNQI) pressure ulcer training. This team is supported by a full-time expert Wound Care Resource Nurse Mary Montejo, RN. The inpatient hospitalist group recognized and valued 3 South’s nursing expertise in wound care. This led to a specific request from Attending Physician Danet Pico, MD for the patient to be transferred to 3 South. (EP5 01 Email from Wound Care Resource Nurse)
METHODS & APPROACH
Nurses’ Involvement
The nursing team utilized the nursing process in planning and delivering the patient’s care.
Assessment
An extensive report between the ICU and 3 South nurses took place. At the time of transfer the patient had wounds to
1. Right anterior upper thigh to knee
2. Left thigh area from ischial tuberosity to knee
3. Right lateral chest wall
4. Right forearm
5. Left forearm
6. Left shoulder into axilla
7. Right chest wall
8. Perineal
9. Sacrum
The patient also had 3 wound vacs in place: 1) to the left lateral chest wall, 2) right lateral chest wall, and 3) sacrum area. The wound vacs were changed 3 times a week - Monday, Wednesday, and Friday. The remaining wounds were cleansed with Saf-Cleans, packed with hydrogel and kerlix, and covered with abdominal pads and medipore tape daily. The outline of the patient’s care communicated to the 3 South staff by ICU made it apparent that a specific plan of care needed to be mapped out for the 3 South staff to meet the needs of the patient.
Planning
Patient Care Supervisors, a Clinical Nurse Educator, Clinical Nurses, and a Wound Care Resource Nurse met and discussed the patient’s wound care needs. The care plan included input from the interprofessional team: physicians, case management, physical therapy and nutrition. The interprofessional team’s goal was to control the patient’s infection and heal the wounds so he could be discharged to outpatient care and eventual self-care. The 3 South nursing team looked at their existing care delivery system (team nursing) and nurse-to-patient ratio. They then devised a plan to deliver the care with the available resources. They decided to divide the wound care between the day and night shifts and spread out the dressing changes on different days. Patient Care Supervisors would oversee the patient shift assignments and rotate it amongst the nurses to minimize fatigue.
Interprofessional Collaborative Practice
Intervention
The patient’s care plan was discussed during stand up reports at the beginning of each shift to ensure continuity of care and address any staff concerns. (EP5 02 September 2013 Stand-Up Meeting Agenda) As part of the patient-and family-centered care approach, nurses conducted bedside shift report during hand-off communication which afforded regular collaboration with the patient and his significant others on the daily plan of care. The wound care resource nurse visited the patient regularly and consulted with the direct care staff. The team documented interventions and patient education in the interdisciplinary plan of care (IPOC) and interdisciplinary patient education record (IPER).Through face-to-face communication and collaboration with the medical, nutrition, rehabilitation, pastoral care teams, wound care resource nurse and 3 South nurses, adjustments to the patient’s plan of care were made as needed in order to ensure continuity and coordination of care.
In addition to managing wound care, the nursing team also focused on providing comfort to the patient. The dressing changes caused the patient discomfort and every step was taken to make him comfortable. The nurses gave pain medications to the patient prior to wound vac changes and daily dressings. The nursing staff ordered a special mattress and repositioned him frequently. To promote relaxation and maximize wound healing, the team dimmed or turned off room lights to afford him frequent rest periods and naps. They also put on Spanish television stations to provide diversional activity and his friends were frequent welcomed visitors to the unit.
The medical staff monitored patient’s response to treatment and consulted infectious disease specialists to manage the infection. Physical therapists worked daily with the patient to increase his muscle strength and mobility that were greatly diminished due to the multiple fasciotomies. Case Management worked on obtaining funding for this patient and got emergency Medicaid for his care and discharge needs. Dietary worked with the patient to support his increased nutritional needs. (EP5 03 Internal Medicine, Dietary and Physical Therapy Notes). Pastoral care visited him to provide emotional and spiritual support.
PARTICIPANTS
The team members involved in the patient’s care in 3 South were as follows:
Name/Credentials |
Years RN / Years Specialty |
Title |
Department |
Role in the Team |
Mary Montejo, BSN, RN, CWS |
31/20 |
Wound Care Resource Nurse |
Surgical Services |
Mentored RNs on wound care and acted as expert resource |
Maikel Luis, BSN, RN, CMSRN |
9/9 |
Patient Care Supervisor |
3 South |
Interim manager |
Aylen Gordillo, RN, CMSRN |
6/6 |
Patient Care Supervisor |
3 South |
Coordinated shift patient assignment |
Nancy Munoz, RN |
10/10 |
Patient Care Supervisor |
3 South |
Coordinated shift patient assignment |
Tracy Moore, RN, CMSRN |
10/10 |
Patient Care Supervisor |
3 South |
Coordinated shift patient assignment |
Nayrovis Gonzalez, BSN, RN |
8/8 |
Patient Care Supervisor |
3 South |
Coordinated shift patient assignment |
Sandy Jones, BSN, RN, CMSRN |
10/10 |
Clinical Nurse Educator |
3 South |
Provided clinical education and mentoring |
Shannon O’Connor, RN |
10/10 |
Clinical Nurse |
3 South |
Direct care Provider |
Judith Misas, BSN, RN |
2/2 |
Clinical Nurse |
3 South |
Direct care Provider |
Giselle Celeiro, RN |
3/3 |
Clinical Nurse |
3 South |
Direct care Provider |
Michelle Ozete, BSN, RN |
6/6 |
Clinical Nurse |
3 South |
Direct care Provider |
Janet Jackson, RN |
20/20 |
Clinical Nurse |
3 South |
Direct care Provider |
Charles Juste, RN |
1/1 |
Clinical Nurse |
3 South |
Direct care Provider |
Beatriz Taboada, RN |
2/2 |
Clinical Nurse |
3 South |
Direct care Provider |
Adrianna Garay, RN |
8/8 |
Clinical Nurse |
3 South |
Direct care Provider |
Shelly Ann Commock, BSN, RN, CMSRN |
8/8 |
Clinical Nurse |
3 South |
Direct care Provider |
Marilyn Napoles Cuesta, BSN, RN |
15/15 |
Clinical Nurse |
3 South |
Direct care Provider |
Rachel Ruiz, RN |
3/3 |
Clinical Nurse |
3 South |
Direct care Provider |
Tina Wolfcale, BSN, RN |
2/2 |
Clinical Nurse |
3 South |
Direct care Provider |
Maria Rocio Ramirez, BSN, RN, CMSRN |
6/6 |
Clinical Nurse |
3 South |
Direct care Provider |
Nadia Vargas, RN |
14/5 |
Clinical Nurse |
3 South |
Direct care Provider |
Nathalie Gautier, BSN, RN |
9/9 |
Clinical Nurse |
3 South |
Direct care Provider |
Svetlana Ramos, RN |
10/3 |
Case Manager |
3 South |
Direct care Provider |
Tracy Seidman, RN, CPHM |
19/6 |
Case Manager |
Case Management |
Coordinated discharge planning and Medicaid application |
Lucy Arcila, RN |
28/20 |
Case Manager |
Case Management |
Coordinated discharge planning and Medicaid application |
Dr. Danet Pico |
10 |
Internal Medicine |
Medical Staff |
Attending Physician |
Dr. Jorge Mejia |
30 |
Infectious Disease Specialist |
Medical Staff |
Consulting Specialist |
Dr. Juan Lopetegui |
25 |
Pulmonologist |
Medical Staff |
Consulting Specialist |
Dr. George Tershakovec |
30 |
General Surgeon |
Medical Staff |
Consulting Specialist |
Dr. Alejandro Sarria Arbocco |
10 |
Cardiologist |
Medical Staff |
Consulting Specialist |
Nicole Trainor, RD |
5 |
Clinical Dietitian |
Nutrition Services |
Direct care Provider |
Kelly Larocca, RD |
10 |
Clinical Dietitian |
Nutrition Services |
Direct care Provider |
Ian Henry, RPT |
13 |
Physical Therapist |
Rehabilitation Services |
Direct care Provider |
Gregorio Marin |
20 |
Chaplain |
Pastoral Care |
Direct care Provider |
Eliane Menezes |
20 |
Chaplain |
Pastoral Care |
Direct care Provider |
OUTCOMES
Ensuring Care Coordination and Continuity of Care
Evaluation
After 4 weeks on the unit, the patient’s IV antibiotics were terminated. His wound healing was progressing to the point the where the wound vacs were discontinued one by one. The patient and his friends were educated with return demonstration on how to do proper wound care. His friends agreed to provide transportation for free outpatient wound care at Homestead Hospital’s Ambulatory Care department twice a week. (EP5 04 Case Management and Nursing Notes) The patient was discharged with oral medications and dressings through the Compassionate Care Program (CCP). CCP is a program that Homestead Hospital provides at no cost to uninsured patients who are not able to obtain medications and supplies for immediate use after discharge. The patient was provided supplies good for 3 days until his first outpatient appointment and the full prescription for antibiotics and pain medications. (EP5 05 HH-400-5180-740 Compassionate Care Medications Policy)
The patient’s biological family came to Miami a short time later after his discharge and assisted in his recovery. The patient was eventually able to do his own wound care with the assistance of his family. Eventually, the wounds totally closed. The patient returned to his baseline functional capacity – ambulatory and independent with his activities of daily living. The patient visited the hospital with his wife 6 months later to express his gratefulness to the team for the excellent care he received. He stated he was looking forward to finding work again.
Summary Attachments/Hyperlinks/Evidences:
EP5 01 Email from Wound Care Resource Nurse
EP5 02 September 2013 Stand-Up Meeting Agenda
EP5 03 Internal Medicine, Dietary and Physical Therapy Notes
EP5 04 Case Management and Nursing Notes
EP5 05 HH-400-5180-740 Compassionate Care Medications Policy
Example 2
NAME OF INITIATIVE
Intensive Case Management of Emergency Department (ED) Frequent User: A Pilot Study to Reduce ED Visits and Promote Primary Care in the Community.
BACKGROUND AND PURPOSE
Homestead Hospital's ED volume has increased each year since the replacement facility opened in 2005 and has reached capacity. Case Management conducted an analysis of frequent ED users and identified 238 patients utilizing Homestead Hospital's ED 5 or more times in the 6 months between October 2012 and March 2013 without an admission. The number of visits ranged from 5 to 26 times in this 6 month timeframe and accounted for 1,632 visits. According to the Robert Wood Johnson Foundation and the New England Healthcare Institute, the average cost difference between an in-office visit and a visit to the ED was $580 in 2007. Shifting the treatment of these patients to a primary healthcare setting could help to decrease the cost per capita of healthcare for this patient population. It would also improve population health by incorporating preventative medicine, not normally addressed in a limited ED visit and assist patient throughput by reducing unnecessary ED volume.
Objective
The overarching goal of the team was to ensure care coordination and continuity by nurses and other professionals. Specifically, they aimed to reduce the number of outpatient visits to the ED by 25% for those patients who accessed the ED 5 or more times without an admission.
METHODS & APPROACH
Interprofessional Collaborative Practice
Every year, a select group of medical staff and hospital leaders are invited to participate in the Gossman Medical Staff Leadership Program. It is a seven month program that provides didactic; one-on-one mentorship with a coach; and hands-on project management to develop and enhance leadership skills. It also provides the participants opportunities for collaborative practice as they embark in the planning and implementation of high impact group projects that are aligned with the organization’s strategic priorities. (EP5 06 Gossman Medical Staff Leadership Program Curriculum) Through this program, an interprofessional team of physicians, allied health professionals, case managers, nurses and other department leaders was formed November of 2012 to address the frequent ED user issue. Using the Plan-Do-Check-Act (PDCA) as framework, the team started by reviewing best practice examples of ED case management programs. They focused the project on ED patients who had 5 or more visits to the ED in the previous 6 month period without an admission. The team reviewed baseline data on these frequent ED patients. ED visits during the baseline period averaged 1.14 visits per month. They also reviewed demographic data, which revealed that 25% of patient visits consisted of uninsured patients while 45% of patients had Medicaid or Medicaid HMO insurance. (Exhibit EP5a) Historically, Medicaid patients tend to utilize ED's more often than other insured patients. This may be due to a lack of primary care, which is an identified community health care need based on the most recent community needs assessment sponsored by the hospital. Only 37% of the baseline patients reported having a primary care physician. The team noted that the lack of primary care was represented in both the insured and uninsured patients. They also analyzed patient diagnoses, which revealed that primary care could address many of the reasons for presentation to the ED. (Exhibit EP5b)
Exhibit EP5a: Insurance Status of Frequent ED Users
Exhibit EP5b: Top 10 Diagnoses among Frequent ED Users
Nurses’ Involvement
Case Management Manager Patricia Brodie, RN was selected as the Co-Chair of the team and worked with ED Medical Director and Co-Chair Otto Vega, MD. Brodie was instrumental in researching best practices. As a result, she proposed a Case Management program in the ED which would extend across the care continuum providing for more patient follow up after discharge from the ED in order to secure the patient a medical home. She utilized the existing case manager job description, with staff spending most of their time on education and follow up rather than communication with payers and traditional discharge planning. She then developed a FTE justification. (EP5 07 FTE justification)
Several meetings with key stakeholders were held to obtain additional input and brainstorm solutions. (EP5 08 Stakeholder Meeting Sign-in Sheets) The group wanted to learn about available services and gain support in promoting primary care as an alternative for this patient population. Brodie coordinated with local clinics, community physicians accepting new patients, behavioral health clinics, and hospice agencies. Two hospice groups and various local clinics were invited and presented to the team how they can help with the patient population.
After conducting a careful review of data and due diligence, the team proposed to Homestead Hospital’s senior leadership the implementation of intensive case management of this patient group. In March 2013, they obtained approval for a 6 month pilot along with an additional 2.5 FTE's in Case Management. The additional FTE allowed staffing 7 days per week for 12 hours during the busiest period in the ED.
Brodie continued her involvement by interviewing and on-boarding RN case managers who were travelers. Bringing this staff onboard required additional resource such as space, furniture, telephones, computers and printers which Brodie helped secure prior to their arrival. Once the traveler RNs arrived, Brodie facilitated meetings with existing clinics and primary care physician offices, case managers, the social worker at Baptist Health Follow up Clinic and herself in order to establish a referral and appointment process. This led to the creation of specific patient files to help ensure the newly hired case managers had current information for patient referrals.
The pilot began in June 2013. The complex task of coordinating a safe transition and follow-up for these patients required a team approach. This interprofessional collaboration, articulated Homestead Hospital’s Care Delivery System, called for the use of interprofessional resources, communication and establishment of community partnerships to achieve the best outcomes for patients and families. Nurses engaged in interprofessional collaborative practice and utilized the nursing process to ensure care coordination and continuity of care as follows.
Assessment
ED clinical nurses were the first point of contact for these high ED utilization patients. They identified these patients upon registration, flagging patients that had 5 or more ED visits within the prior 6 months. This was a key component of the program as early identification allowed the case manager to meet with the patient and begin a transition program during their ED visit.
Planning
In collaboration with the ED physicians and ED clinical nurses, ED case managers then developed a care plan for safe transition of these patients to primary care. Barriers to primary care included noncompliance with outpatient PCP visits, lack of funding, lack of understanding regarding the need for primary care and the ease of our ED care delivery system including free transportation via ambulance and no co-pay collection. ED clinical nurses provided patients with information on free and low cost clinics (EP5 09 Community Resource Guide) All patients identified as high ED utilization patients met with the case managers during the ED visit in their office adjacent to the ED. After discharge from the ED, the case managers acted as liaisons and contacted them a minimum of 4 times to ensure the patient’s transition plan was successful.
Interventions
ED pilot case managers, Iona Afflick, RN, Ashley Sessions, RN and John Dempsey, RN met with the patients and their families prior to discharge. They assisted the patient in PCP or clinic selection and scheduled a follow up appointment for the patient before discharge from the ED, when possible. They provided assistance with transportation arrangements, if needed, through the use of the public trolley and various clinics offering free transportation. They also helped many patients complete the financial assistance program application that would help to secure long term funding such as Medicaid or Medicare and or charity care approval for services at BHSF in collaboration with the Business Office.
Evaluation
After patients were discharged from the ED, the ED Case Managers made discharge call backs within 24 hours to confirm follow up care. They followed these patients closely by making additional calls over the next 4 months, working with the local PCP's and clinics to ensure the patient kept the scheduled appointment and rescheduling appointments, if necessary. Close collaboration with the ED physicians, ED nurses, patient and family as well as PCP or clinic staff was critical to the success of the program.
PARTICIPANTS
Name/Credentials |
Title |
Department |
Role in the Team |
Patricia Brodie, RN |
Manager, Case Management |
Case Management |
Co-Chair |
Iona Afflick, RN (Traveler) |
ED Nurse Case Manager |
Case Management |
Ensured care coordination and continuity of care among ED high utilization patients |
Ashley Sessions, RN |
ED Nurse Case Manager |
Case Management |
Ensured care coordination and continuity of care among ED high utilization patients |
John Dempsey, RN |
ED Nurse Case Manager |
Case Management |
Ensured care coordination and continuity of care among ED high utilization patients |
Lucy Arcila, RN |
Nurse Case Manager |
Case Management |
Member |
Judy Bird, BS, RN |
Clinical Nurse |
Emergency Department |
Member |
Pascale Francis, MSN, RN |
RN Case Manager |
Case Management |
Member |
Linda Long, MBA, MSN, ARNP-BC, CHPN |
Manager |
Palliative Care |
Member |
Martha Bertin, MSN, ARNP |
Nurse Practitioner |
Hospitalist Program |
Member |
Cary Madruga, CSW |
Social Worker |
Case Management |
Member |
Netonua Reyes, RN |
Pediatric Emergency Department Manager |
Emergency Department |
Member |
Ashley Sessions, RN |
RN Case Manager |
Case Management |
Member |
Jill White, RN, CPHQ |
Performance Improvement, Case Management and Medical Staff Services Director |
Performance Improvement |
Member |
ED Clinical Nurses |
Clinical Nurses |
ED |
Primary nurse and initial point-of-contact for ED high-utilization patients; made referrals to the ED case managers |
Desdemona Wooten, RN |
Quality Assurance Nurse |
Emergency Department |
Member |
Carla Green, CSW |
Social Worker Case Manager |
Case Management |
Member |
Marie Ade, PharmD |
Director |
Pharmacy |
Member |
Otto Vega, MD |
Medical Director |
Emergency Department |
Co-Chair |
Mark Weinstein, MD |
Physician |
Emergency Department |
Member |
Mohammed Ali, PA |
Physician Assistant |
Emergency Department |
Member |
Arelys Carasa |
Business Planning and Development Manager |
Planning |
Member |
OUTCOMES
The components of the pilot program included working closely with community agencies to identify sources of care for unfunded patients, partnering with the patient and family to gain commitment and compliance with plan, scheduling follow up primary care appointments and making follow up calls to ensure the patient saw the provider, rescheduling appointments, if needed, and reinforcing teaching.
Exhibit EP5c: Average ED Frequent User Visits
Analysis: After the first 6 months of the program, ending November 2013, patient visits per month decreased 63%, from 1.14 visits per month to 0.42 visits per month. This was accomplished through intensive case management of this patient population. This represented a decrease of more than 1,000 patient visits or 2,000 visits annually. Sixty patients were successfully transferred to a medical home and 2 patients were transitioned to hospice.
Summary
The project was successful in reducing the average visits to the ED from more than one visit per month to one visit every 5 months. The team exceeded their goal of reducing the number of outpatient visits to the ED by 25% for those patients who accessed the ED 5 or more times without an admission. Furthermore, the case managers successfully transitioned 112 patients to a medical home during the pilot. While the decision was made that the pilot program could not be extended, the lessons learned will be utilized in the hospital’s plan for expansion into primary care within the next couple of years as this is an opportunity for our community.
Summary Attachments/Hyperlinks/Evidences:
EP5 06 Gossman Medical Staff Leadership Program Curriculum
EP5 07 FTE justification
EP5 08 Stakeholder Meeting Sign-in Sheets
EP5 09 Community Resource Guide
Exhibit EP5a: Insurance Status of Frequent ED Users
Exhibit EP5b: Top 10 Diagnoses among Frequent ED Users
Exhibit EP5c: Average ED Frequent User Visits