Care managers help improve quality of care
Rehab patients benefit from seamless care
When a trauma patient first enters the 360-bed Gundersen Lutheran Medical Center of La Crosse, WI, and is admitted to the intensive care unit (ICU), the patient is assigned a care manager who stays with the patient until he or she is discharged from inpatient rehabilitation.
The care manager role, particularly having one care manager follow a patient through each medical setting, is crucial to the quality of care in the rehab facility, says Linda Wieczorek, BSN, CRRN, staff nurse on the hospital’s 17-bed rehab unit.
"The care manager is serving patients to make sure all their needs are met," Wieczorek says. "Previously, we had a care manager in ICU, then when the patient transferred to the medical or surgical floors, there would be a brand new care manager, and then when the patient arrived on the rehab unit, there would be another care manager."
That resulted in communication problems and other issues because the patient and family continually had to explain their concerns and difficulties to staff, Wieczorek explains.
To solve those problems, Gundersen Lutheran Medical Center started the continuous care management program several years ago as a way to provide continuity of care to ICU patients and their families. Cathy Bly, BSN, one of the two nurse care managers, works with patients who have suffered from a spinal cord injury, brain injury, or other type of trauma. "Everybody is unique, and it’s important for us to know what kept a patient comfortable at home and what strategies worked at home so that we can provide a less threatening environment for that patient," she says. That’s Bly’s job — to find out what a particular patient needs and to communicate those needs to the staff in ICU, acute care, and rehab.
The hospital hasn’t measured outcomes since beginning the continuous care management program, but Wieczorek says the anecdotal evidence suggests it helped the rehab facility reduce lengths of stay and improve quality in patient care. "It has been real positive for patients to have a trusted person right with them through their recovery," she says. Also, rehab staff benefit from having one person they can contact if they need to give the patient’s doctor or family some new information about the care plan.
Here’s how the program works:
1. The care manager assesses patients after ICU admission. Bly completes a tool called the Functional Health Patterns Assessment based on what she learns from the family of new patients. When a patient is able to answer questions, she will confirm the family’s answers with the patient.
That tool, which takes about 10 minutes to complete, gives Bly an overview of the person’s life, including questions about how the patient eats and sleeps, elimination issues, who the patient’s supports are, how the patient copes with problems, overall health issues, and spiritual aspects of the patient’s life. "This gives us a pretty good picture of the patient," Bly says.
She uses the information to create a more comfortable environment for the patient. For example, if a patient enjoys a certain television show, Bly will write this into the care plan, so hospital and rehab staff can remind the patient when that show is on. The same strategy is used to find music and other activities the patient enjoys.
During the most traumatic and intensive part of a patient’s hospital stay, Bly meets with patients and their families about twice a day. She typically checks in with the family and patient during the mornings and then again in the afternoons.
"Sometimes, the families are so overwhelmed with the big words and complexities of the medical equipment that they want someone to decipher what is happening," Bly says. "So I sort of become a communication link."
Likewise, if a physician has told the patient and family something they don’t understand, Bly checks with the physician to get a clear answer for them. She also meets daily with dietitians, social workers, chaplains, and other disciplines to discuss the patient’s care.
2. The care manager develops relationships with the patient, family, and staff. Soon, patients and their families begin to trust Bly and see her as their advocate and liaison. "They begin to trust my judgment, and things move smoother for them," she says. She is, in effect, a buoy in an ocean of uncertainty for parents of young people with brain injuries. "I’ve shared a period with them when we don’t know if their son or daughter is going to live or die, and consequently, we often become buddies in this tragedy," she explains. "I know what the families are going through, and I can give them some encouragement."
Another stressful time is when the patient leaves the ICU and is moved into another area of the hospital. The family and patient sometimes are frustrated because they suddenly have to start all over meeting a new staff of nurses. Bly provides some continuity in their experience, because she will be with them whether they have moved to acute care or directly to the rehab unit.
Since Bly became a care manager for traumatic injury patients, she’s often convinced the rehab team that certain patients do not need to be transferred from the ICU to acute care before entering rehab. "We can transfer a patient directly from ICU to rehab so the patient and family don’t have an intermediate stop. For the cases where that has happened, it has worked out very well."
She convinces the rehab team that some patients will not have medical problems too complex for the rehab unit to handle. The rehab team has grown to trust Bly’s judgment and usually follows her suggestions. "I’ve had 100% success with the ones I’ve sent over to rehab," she says. "I know the work that’s involved, and I don’t want to see someone fail." She also paves the way emotionally for rehabilitation patients. "Within a day or two, if we have a patient who is going into rehab, I start to get the staff psyched. I commit to my patients, and I want the staff to like them as much as I do."
3. The care manager provides unique services to patients. Care managers work very closely with patients and their families and therefore have some opportunities to provide services that are out of the ordinary. "I try to see each patient as being unique and try to get the things that person specifically needs," Bly says.
For example, one of her patients was a grandfather, so she made sure he received some photos of his new grandchild. Another patient was a from a foreign country and needed to return home after his injury. Bly made phone calls to airlines to check their weight limits on baggage and packages and then, along with volunteer help, assisted the man in packing his belongings in boxes that were under the 70 lb limit. The hospital even sent someone with him on the plane trip because he needed assistance with his wheelchair.
"There aren’t any specific boundaries to what you can do with this job," Bly says.
She also prepares patients and their families for rehabilitation and the subsequent changes to their lives. "I educate the family of what to expect, like if they need ramps or 24-hour supervision. This way, it’s less overwhelming for the family to deal with the patient’s disability because we’ve been talking about the changes from the start."
Early on, she provides families with manuals on head injury and spinal cord injury. The families have plenty of time to read them and ask her questions as the patient progresses.
4. Care manager provides follow-up care. When patients are discharged, Bly calls their homes to see how things are going. She also sees them when they come in for appointments. "This is a plus with the families because, if you’ve been with them for an extended period of time, they like to see you again," she says.
If a patient is readmitted to the hospital or rehab unit for any reason, Bly is automatically identified as the care manager. That, again, provides the family with reassurance and gives the patient an added dimension to the continuity of care.
Need More Information?
Cathy Bly, BSN, Care Manager, Gundersen Lutheran Medical Center, 1910 South Ave., La Crosse, WI 54601. Telephone: (608) 785-0530, ext. 3124. Linda Wieczorek, BSN, CRRN, Staff Nurse, Rehab Unit, can be reached at the same address and phone number, ext. 3261.
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