Hospital blazes new trails with cross-continuum case management program
Discharge planning, patient education improved
Nurse managers at a Wyoming hospital envisioned a case management system for coordinated cross-continuum care for a rural county, but they had no idea the actual program would become so far reaching.
Called the Community Rural Health Project (CRHP), case managers at Ivinson Memorial Hospital in Laramie now receive detailed information on patients prior to admission thanks to home health involvement. In one year, hospital staff have implemented critical paths, improved the discharge planning process, and developed a patient education booklet.
The program was created because "there was no coordination of care in managing patients from pre-hospitalization to post-discharge, and there were delays in discharge planning," says Terri Morris-Nichols, RN, surgical-orthopedic nurse manager at the 99-bed facility and
co-developer of CRHP.
As a result, a pre-hospitalization home survey was developed with the help of Kathy Moore, RN, BSN, patient care manager at Wyoming Home Health, also located in Laramie. Home health nurses now use the home survey in satellite offices across the state, so patients as
far as 500 miles away from the hospital still can be surveyed before admission, notes Moore.
The survey serves as an information gathering tool and benefits both the hospital discharge planner and home health nurse. Data collected from the six-page surveys are sent to the hospital discharge planner prior to the patient's admission.
If a home health nurse is unable to conduct an on-site personal interview, the survey can be completed by patients themselves or via a telephone interview. "The best approach is to have an on-site evaluation to spot potential problems early. But the program is designed so that the same person who sees the patient during the pre-hospitalization assessment is the same person the patient sees if he or she needs home health services after hospitalization," explains Morris-Nichols.
Although it's too early to determine whether length of stay (LOS) has dropped since implementing the program, there is a definite reduction in last-minute scrambling and delays in discharge, says Morris-Nichols. Outcomes data on reduced days and costs will not be analyzed until early 1996.
The pre-hospitalization survey is divided into four main sections:
* identification of family and community support systems;
* description of home environment;
* brief medical history and physical status;
* review of pertinent data, such as advance directives and insurance information.
"The pre-hospitalization home survey has eliminated any lapses in communication. Before the survey, home health nurses would go into the patient's home and find things that weren't indicated in the hospital's discharge plan. The patient takes the home environment for granted and doesn't objectively look at potential safety hazards. Our approach is to go into the home and spot potential problems to smooth the discharge process," explains Moore.
The family and community support systems section, for example, calls for the home care nurse to document several probable caregivers and contact people for the patient. The person's name, relationship to the patient, and telephone number are noted on the survey. In addition, the survey asks: "Will the above mentioned person(s) be available following your hospitalization to:
* prepare meals;
* obtain groceries;
* get medications from the pharmacy;
* give medications;
* assist with housekeeping;
* assist with finances?"
Patients are reminded of their surgery date and time, and given preliminary instructions. General information about hospital policies is also provided, such as the hospital's no smoking policy. Patients can even indicate during the survey if they would like to enroll in the hospital's smoking cessation program.
Survey yields new assessment
Morris-Nichols, who also manages social service functions at the hospital, changed the hospital's social assessment to match the pre-hospitalization survey. "I set up a brand new social assessment. The assessment is gathered prior to the hospital stay or during admission using the information gathered from the survey," adds Morris-Nichols. Social assessments used to be obtained from information on the physician's order, but the new process has increased caregivers' awareness of risk factors, notes Morris-Nichols.
The pre-hospitalization home survey also is being used by another home health agency and the University of Wyoming, located in Laramie. Having increased cooperation among providers enables patients in remote areas to be surveyed before hospitalization. "There have been delays in the past from simple things like a patient not being able to be discharged because they can't fit in their car's passenger seat with braces," adds Moore.
CRHP was developed in December 1994 and open to other community providers, but the nurses never imagined the program would get such broad community involvement, says Paula Crespin, RN, medical-telemetry nurse manager and co-developer of CRHP. The project now involves a home health agency, a physician organization, senior centers, pharmacy, and public health clinics. "CRHP is now including a disease prevention component through Well Aware, a community organization composed of volunteer organizations committed to improving public health in Albany county, where Laramie is located," explains Morris-Nichols. Well Aware, sponsored by the hospital and in its fifth year, is targeting the top 10 public health issues in the county that were identified through the hospital's morbidity and mortality data.
In addition to the pre-hospitalization home health survey, CRHP includes coordinated critical paths that are used across the continuum. Critical pathways currently in development or recently completed include the following treatments and procedures:
* angina;
* total knee replacement;
* alcohol detoxification;
* vaginal delivery;
* cesarean delivery;
* low-birthweight infants;
* newborns.
Included on each pathway are the following sections: nursing care; medications; pain management; diet/nutrition; elimination; cardiopulmonary; lab results/replacement therapy; mobility rehabilitation; teaching/education; and social services/discharge plan.
The three-page path for total knee replacement, the first to be developed, covers the day of surgery and five days thereafter. Documentation by exception and a system of codes for recording outcomes and interventions keep the paperwork simple and efficient.
Within the next month, patients admitted to Ivinson will receive a patient education booklet designed to explain the concept of the critical path and purpose of case management. One booklet was developed for total knee replacement and another booklet covers other surgeries and procedures.
"The booklet provides general information and walks patients through their own pathway. Patients learn about their path through three sections: Your Care, Reasons for Your Care, and What You Can Do to Help in Recovery," Morris-Nichols explains.
Patients who receive an IV, for example, are educated using a three-step method with the following instructions:
* You will receive an intravenous catheter to receive fluids and medications.
* The IV provides nutrients and minerals and allows nurses to administer medications for pain and infection control.
* Let the nurse know if the IV causes pain or discomfort.
Ivinson's approach to case management involved the community from the beginning. Prior to developing CRHP, Ivinson had no case management model in place. "We invited the community to attend our first hospital meeting. After talking, we found that the other community agencies had similar goals and parallel projects, so we decided to work together," says Morris-Nichols.
Involving other providers in the development process has increased staffs' understanding of health care beyond the hospital walls, Morris-Nichols says. "We are more aware of the spectrum of care and found that there's a lot of expertise within the community that we can access."
For example, the collaboration is leading to the development of a community health information network (CHIN) in the county. CHINs are electronic networks for relaying and sharing clinical, administrative, and financial data among physician offices, hospitals, home health agencies, and outpatient clinics. "The process is becoming more confusing the more we look into it, but we're finding that we will have to evaluate how the hospital's actions will affect other members of the community," says Morris-Nichols.
A community task force currently is researching the possibility of sharing clinical information. Both the existing case management and information management committees within the hospital are on the task force. "There are so many things to consider, such as the type of interface engine we'll use and technical aspects," Morris-Nichols says.
Funding for the CHIN is expected to come from a combination of grants and contributions from participating organizations. "A lot of that is not clear yet, but a member of the task force has experience in grant writing, and they've agreed to help," Morris-Nichols says.
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