Cross the continuum divide with 'firm' footing
Patients not lost in acute-to-outpatient shuffle
Patients admitted to an Ohio Veterans Affairs hospital are benefiting from a team approach that uses case managers to smooth the transition from the hospital to outpatient care.
Surprising in this era of downsizing, the Cleveland Veterans Affairs Medical Center is creating -- rather than eliminating -- separate entities within the hospital to perform cross-continuum case management duties. The 360-bed facility has divided its four general medical units into two sections, called firms, which employ two case managers each.
A firm is defined as a group of professionals who provide care for a specific group of patients, explains Sandra Schurdell, BSN, RN, NCM, one of the hospital's four case managers. Through this system, the case managers work on the medical units and in the medical outpatient clinics each day, dividing their time as necessary to coordinate patient care.
The two firms, A and B, each consist of two
22-bed general medicine units. In addition to the case managers, each unit employs a nurse manager, nursing staff, and unit clerks. Also assigned to each firm are the following staff:
* first-, second-, and third-year residents;
* attending physicians;
* medical director;
* clinic director;
* pharmacist;
* physician's assistant;
* clinical LPN;
* dietitian;
* social worker;
* unit clerk.
Inpatients are assigned to a firm according to the last digit of their social security number -- even numbers to firm A; odd numbers to firm B.
Adding in case management as part of the reorganization is working much better than the hospital's original attempt at case management four years ago, says Schurdell. At that time, the internal support system for pathway use was not in place. In fact, pathway use went by the wayside several years ago at the medical center when the associate chief of nursing, who promoted pathway development and use, left the hospital.
With the shift to a team management approach to care and the need to better coordinate care across the continuum came a renewed interest in pathways.
Staff education key to success
Staff education played a key role in creating the firms. Clinical inservices are held to teach new procedures on the units. Monthly firm meetings are held for both the nursing and medical staff. Also, the nursing staff meets monthly with the associate chief of nursing.
Ongoing medical education and assessment skill improvement are provided to the case managers by the clinic director, who serves as medical preceptor for the firm.
Schurdell explains that the plan has resulted
in better patient coordination and stronger case manager/physician ties. Better coordination also enables the facility to manage a larger number of outpatient visits, which have increased from 8,000 in 1991 to about 16,000 in 1995, says Schurdell.
"The patients don't get lost in the system like they used to," she says. Furthermore, certain steps have been put into place to make coordination across the continuum much smoother, as the case managers follow each patient's treatment plan and ensure that necessary outpatient appointments are scheduled. "For example, we don't give patients any medication refills until the outpatient secretary has made them another appointment in the clinic."
Of all the staff involved in the two firms, it is the case managers who remain a constant in both the inpatient and outpatient care, explains Schurdell. Each case manager reports to her respective nurse manager, under the auspices of nursing administration.
A lot of autonomy, including flextime, allow the case managers to plan their schedules most effectively. Each case manager, however, works a standard 40-hour week. "We all start work at different times. I'm one that likes to be here at seven. I begin by pulling up all the data on the new patients on the ward and checking the computer for pertinent information such as lab results. We also make rounds in the mornings for about an hour with the medical team," says Schurdell.
Case managers typically divide their time equally between the hospital and outpatient clinic, which are housed in the same facility, but on different floors, says Schurdell. "Each ward is
a bit different, so each case manager functions a little bit differently depending on the needs of the ward. If there is not a lot of teaching to be done on the ward or problems that I need to deal with, like getting the home health forms filled out, then I tend to be more in the clinic because I manage a lot of diabetics."
Primary functions performed by the firm case managers for both inpatient and outpatient duties include the following:
* Make rounds with the medical staff.
Making the rounds with the medical staff helps the case managers begin discharge planning, and provides them with crucial information about each patient's diagnoses, test results, and anticipated treatment plans for each day, says Schurdell. The case managers work closely with physicians during this process, informing them of the appropriate forms that must be completed as the patients transfer either back home or to the outpatient setting.
* Receive consults from clinic residents.
After rounds are completed, the case managers' work time is rotated between the clinic and the unit.
Each firm has one clinic examination room assigned to the case management teams. The case managers receive consults from the clinic residents and unit residents for early follow-up after medication changes and to aid them in their patient teaching.
The case managers schedule their own appointments and check the computer to avoid scheduling conflicts.
* Perform discharge planning functions.
Discharge planning is one of the case managers' primary functions. Specifically for this process, the case managers ensure that:
-- patients have follow-up clinic appointments;
-- visiting nurse association and nursing home referral forms are completed;
-- home care equipment has been ordered.
Case managers complete nursing assessments for patients who are expected to be followed into the outpatient clinic.
Case managers carry in-house pagers so that patients, after being discharged to the appropriate setting, can contact them if problems or questions about their care arise. In addition, the case managers give each patient their business card so that future questions or concerns can be handled.
Consults conducted in clinic setting
* Review medications.
During the clinic visits, the case managers perform a diagnosis-related history and physical. Medications are reviewed for accuracy and compliance. The case managers also ensure that patients have enough refills of any prescriptions until their next physician visit.
* Perform dietary patient education.
Case managers are responsible for ensuring that patients on restricted diets understand what they can and cannot eat. Compliance is noted in the patient record, and the case managers write
a consult to the dietitian if patients need more information or help in understanding their diet.
* Write up consults.
In addition to dietary consults, other consults are written as needed, such as those for the mental health clinic. If lab work is needed, the case managers write a request, keep track of results via the computer, and perform any follow-up work on significantly abnormal results.
Schurdell closely monitors diabetic patients with abnormal lab results, such as elevated blood glucose levels. Results are reviewed by Schurdell and then followed up with the patient. Recommendations or suggestions about decreasing blood glucose levels are provided to the patient, adds Schurdell.
Documentation in the clinic is done on a consult sheet, which is duplicated via a carbon copy for the case managers' files. Individualized forms with more specific information were developed for diabetes and hypertension patients. The consult sheets prevent delays in obtaining information from either having to pull the chart, or if the chart is not available for a clinic visit.
Schurdell says the program has given all patients a consistent resource whether they receive care in the inpatient or outpatient setting. "Previously, patients did not have the same doctor necessarily. There was a gap in patient teaching, and there wasn't the constant follow-up that we have now."
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