Team care management = lower lengths of stay
Patients, caregivers, CMs work closely
At Griffin Hospital in Derby, CT, the patients’ care is managed by their primary care nurse, their case manager, and by the patients themselves. As a result, the nonprofit hospital’s lengths of stay are at or below the averages reported by the Centers for Medicare & Medicaid Services.
Griffin Hospital doesn’t have a central nursing station. Instead, it has a primary care nurse model, which bases nurses right outside a patient room with a clear line of sight into the rooms. The stations have a computer, medical records, and basic supplies.
During the day, there is one nurse for every four beds. During the second shift, there is one nurse for every six patients and one for every eight patients on the third shift. The primary care nurse works closely with the case manager to coordinate the care.
It’s all a part of the Planetree health care model, adopted by Griffin in the 1990s.
"The Planetree philosophy is to look at the patient as the priority, rather than having a physician-centered or provider-centered focus," says Bill Powanda, vice president of Griffin Hospital.
The concept makes patients equal partners in decisions that affect their care and well-being.
"The educated and involved patient is a partner in the care process, rather than being a bystander," Powanda says.
When patients are admitted, they receive a packet of information about their diagnosis and are made a member of the care team. They attend care conferences and get a patient pathway, a printed brochure in lay language that outlines what tests and procedures are done each day for their diagnosis. The primary care physician, primary care nurse, case manager, and ancillary services such as physical therapy, respiratory therapy, and the hospital dietary department all meet regularly with the patient.
The hospital’s continuing care department, staffed by nurse case managers, works in tandem with the primary care nurses and attendants.
Griffin Hospital has combined the utilization review, case management, and discharge planning departments. The hospital’s six full-time case managers and two part-time case managers handle all three functions. The typical caseload is between 12 and 15 patients at a time.
"Prior to that, there were a lot of obstacles and delays. There were different people doing different pieces and often there was a break in continuity. The case manager is supposed to know the whole story of the patient, and we’ve found it works better this way," says Kathleen Martin, RN, BSN, A-CCC, CCM, CPC-H, director of continuing care/medical records.
The case managers are assigned to floors. Every morning, they sit down with the charge nurse and review what is going on with the patient.
They find out if the patient’s progress is on schedule, if the laboratory work was normal, or if there will be delays in discharge.
The case managers handle discharge planning, work with the patients and primary care nurses to set up whatever the patient needs after discharge, and work with the physicians to make sure they are following the clinical pathways.
"I teach my case managers to be patient advocates. They have to balance what is happening with the patient now with what is going on at home and what is available in the community," Martin says.
The case managers talk to any outside providers that may have been caring for the patients, talk to the family and patient, and review the patient status on a daily basis with the insurance company. "Meanwhile, they are working daily with the family to set up a safe discharge. We try to give the family as many options as we can. We look at insurance contracts, home care agencies, and community services," Martin says.
As soon as the patients are stable, the case managers discuss their options in detail with them, set up a home care agency if necessary, ensure that durable medical equipment is available, and make sure their transition to home is smooth. "We want to make sure that everything is in place for optimal recovery when the patient walks out the door," she says.
About 48 hours after discharge, the case managers call the patients and family to find out if anything could have been done better.
When a patient is scheduled for elective surgery, such as a total hip replacement, the case managers work with the patients and physicians before admission. "That way, the patient will feel comfortable coming in and know in advance what to expect," she says.
The case managers work with the ancillary department, the primary care nurse, the primary care physicians, and the therapists to get a full picture of what is going on with the patient.
"We have been working to change an entire culture. We try to get physicians to deal with all the patient problems concurrently. In the past, if the doctor came in and a patient had an issue, the physician would take it up and take up the next one later. We try to look at the big picture," says Martin.
The hospital tracks outcomes and variances in length of stay. A utilization manager looks at any kind of internal or external reason to see where areas of improvement can be.
Each case manager has a worksheet on which he or she tracks patient progress. A data analyst enters the date in aggregate form. For instance, one frequent delay in discharge occurred when patients were in the hospital and waiting for an operating room. The hospital’s solution: to open up another operating room.
When a lot of patients were staying in the hospital while waiting for dialysis, the hospital arranged for the patient to go home and wait, rather than staying in the hospital until there was a permanent slot. "Data help us see where we can improve. It’s helpful from all different perspectives," Martin says.
The hospital also employs a hospitalist who facilitates coordination of care and is available as test results come back to adjust the medication or order additional tests. Hospitalist services are used by primary care physicians who have busy practices and often are unable to be at the hospital for extensive periods of time. The service is voluntary, and some physicians prefer to manage the hospital care themselves.
At Griffin Hospital in Derby, CT, the patients care is managed by their primary care nurse, their case manager, and by the patients themselves. As a result, the nonprofit hospitals lengths of stay are at or below the averages reported by the Centers for Medicare & Medicaid Services.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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