End dysfunctional communication with docs
Team up for a more efficient, profitable agency
Continuity of care or the lack thereof is a problem affecting hospital-based home care agencies and their patients. Patients dislike the steady stream of unfamiliar faces waltzing through their homes. Nurses, meanwhile, complain of the lack of control over patient care, and administrators wish they could somehow reduce the staff time required before each visit to track down the necessary files and charts.
Many home care agencies are migrating to a "team approach" to home care to solve some of these continuity-of-care problems. Teams of nurses are most frequently assigned to certain patients, usually by geography but also by specialty.
Hospital Home Health spoke with Peter Boling, MD, Virginia Commonwealth University-Medical College of Virginia and president-elect of the American Academy of Home Care Physicians, who provides examples of how his own team of doctors and nurses works to provide a continuity of care rarely seen in home care settings. Additionally, Ann M. Morris, RN, MPH, executive director of the Instructive Visiting Nurse Association (IVNA) in Richmond, VA, provides insight on how her agency has worked with Boling’s team.
To enhance continuity of care, Boling’s team from his hospital performs the medical portion of home care. Patients enrolled in home health care in his program are seen periodically by his "internal team," which consists of the physician, nurse practitioner, and social worker.
His team consists of the full-time equivalent of 1.5 physicians and two nurse practitioners and has about 150 patients. The physicians on the team are full-time faculty members of the medical center, and the nurse practitioners also are hospital employees.
"My team is like an extension of a physician’s practice," he says. "You could think of us as home care specialists. In the same way there are cardiologists and orthopedists, we are home care providers clinicians and nurse practitioners who know and do home care.
"Think of that as a doctor’s office on wheels," says Boling. "They’re doing the same thing that would be done in a doctor’s office but doing it in the home."
Here’s how Boling’s team helps the home health agency promote a continuity of care for patients:
• Team assignments.
Boling’s team approach carries over to IVNA. Of his team’s patients, there are usually about 40 open to the home health agency, which assigns those patients to a handful of their nurses, providing a continuity of care not only on the medical end but also on the home health end.
• Daily communication.
Boling notes that one of the weakest parts of home care is the communication between the agency and doctor.
"It tends to be a very dysfunctional type of communication difficult to set up and not very satisfying to the different parties."
He recommends defining the plans for communication early on with physicians by considering how you want to communicate information and for the information that goes to the doctor to be easy to read and complete.
For example, each day Boling’s team communicates by phone or fax with staff at IVNA to touch base on that day’s patient visits and the progress of other patients.
Establishing such communication is often difficult.
"Ordinarily, it is nearly impossible for home care nurses to interact with primary care physicians," notes Morris. " The heavy demands on their time, the unique needs of frail elderly patients at home requiring frequent assessments and almost equally frequent changes in treatment plans, coupled with the demand for high-quality standards of practice are prohibitive."
• Monthly meetings.
Once a month the "extended team" the home health agency team and Boling’s medical management team meets and reviews the common cases. Boling says the majority of cases take just a minute or two each, while a handful (five or six) of the more complex cases may take five or 10 minutes each.
"These are regular meetings with the primary care physician pacing and coordinating the information shared among nurses, social workers, nurse practitioners, home health aides, physical therapists, occupational therapists, and speech therapists as need demands," says Morris.
Nursing care managers attend the meetings, while nursing supervisors occasionally sit in.
• Staff-patient familiarity.
While agency nurses don’t visit a patient who is admitted into the hospital, Boling’s team does, providing continuity of care for that patient. The opposite would be true for a hospital-based agency, though.
"From the point of view of the nursing continuity, it would be easier for a hospital-based agency, assuming they made it a priority," he says. "The nurses would be in and out of the hospital facility, so they would have an opportunity to become familiar with the hospital patient.’’
Morris notes the following benefits of incorporating primary care physicians and home care staff into one team of caregivers:
Direct access to the primary care physician is available.
Doctors make available to the home care agency staff information on new medical treatments.
Adverse reactions to treatments are noted early on and reported to the physician early on thanks to the frequent contact, resulting in improved patient care.
With physicians-in-training taking part in the program through the medical college, Morris adds that these physicians "learn how to best integrate home care into their medical practices in the future."
Why include doctors?
While the team concept is simple, its implementation often is not. For example, how far do you take the team approach? Do you limit teams to your own staff, or do you attempt to include physicians and others outside your home care agency?
"It’s important to define who you think are members of this team," says Boling.
When forming teams, Boling suggests including the traditional home care agency staff the nurse, the therapist, the nurse’s aide and social worker from the home health agency. But he also suggests considering other individuals critical to the patient’s health. These include a physician, the caregiver who does most of the work and is often a family member, and ancillary members of the team, such as discharge planners and individuals who design but don’t carry out the home care plan.
"They’re very important participants in this process because they know the most about the medical conditions, as well as knowing the most about what went on in the hospital," says Boling.
In an ideal situation, the team provides continuity of care regardless of the patient’s location home, ER, or hospital. Switching from one set of physicians and nurses to another each time a change of location takes place leads to a lack of an in-depth understanding of what took place in the previous setting.
"You not only are inefficient but you do things that don’t make sense clinically," says Boling. "When you don’t have a team approach, people have to rediscover information that is already known to other people. And if the patient doesn’t get good care, they are liable to have recurrent hospitalization and ER visits."
Joanne Lamprey, RN, president of InterQual, a North Hampton, NH, company that provides medical appropriateness review systems, credentialing, and quality services to the healthcare industry, agrees.
"It is essential that continuity and familiarity be key components of the planning and staffing process," she says. "If the patient is going to a hospital-based agency directly from the hospital, a more integrated, comprehensive approach with team members can occur prior to discharge. As patients are being discharged from the hospital sicker,’ it is essential that the physician be an integral member of the team."
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