Community program helps patients, agencies
Award winner takes pressure off home care
Hearing about Middletown (OH) Regional Hospital’s case management program two years ago raised some concerns for area home care agencies. Agencies feared either the program could take patients from the agencies, or there would be new administrative duties attached to patients referred to those agencies. But for the agencies involved, the program has been nothing but a plus.
Jayne Morgan, RN, acting supervisor and case manager at Dayton’s Home Health Plus, says there is little additional work for her 18 nurses. In some cases, the case managers at the hospital have been able to actually alleviate some paperwork burden from her staff. The Middletown program, which was recently given a NOVA award by the Washington, DC-based American Hospital Association, is designed for patients with complex health issues who had been presenting repeatedly at urgent care or emergency facilities.
According to Carol Turner, FACHE, vice president of clinical and information services at the hospital, readmission rates were becoming a problem, too. As a result, 15 community leaders got together to create a case management program.
"This was a way for the community to work together to improve health status among our citizens," Turner says. "We worked with hospices, parish nurses, home care agencies, and other health care providers to make sure that patients could move through a seamless system."
The hospital wanted a "community-based case management program, but we wanted it to be management in all areas where patients receive care, not just one episode of care," she says.
The resulting program has serviced some 180 patients in the last two years. According to Morgan, the only additional work for her staff is to make sure the case managers at the hospital get copies of lab reports, case conference notes, and intake forms for patients. "Most of our interaction is over the phone — case manager to case manager. They call us and tell us if there is a need, and our case manager contacts them if there are any issues," she says. (For specifics on features and requirements, see box, below.)
While the referrals have all been one way so far, Morgan says there is no reason why the home health agencies couldn’t return the favor, referring patients who might benefit from case management to the hospital.
The impact on patients has been significant, she adds. One patient had a chronic foot ulcer. At one point, amputation was considered. After months of daily home care visits, he was healed. However, his mobility and motivation recently decreased, and at a monthly visit for a catheter change, Morgan’s nursing staff found some suspicious areas on one of his legs.
"We thought he needed some extra visits," she explained. "We called the community case manager, and she called the insurance company. She acted as intermediary and got us the extra visits."
That action saved the agency time, brought it more business, and was beneficial to the patient as well.
Other agencies also are happy with the program. Kelli Haberthier, RNC, administrator at Cincinnati’s Spectra Care likes the additional communication she gets about patients.
"If they go into the hospital, we know we’ll get a call," she says. "I see it as us working together to benefit the patient."
Even when a patient has been discharged, Haberthier and her staff are informed about that patient’s progress or setbacks. That way, if the patient returns to home care, there is more complete information on his or her condition.
"There really is no down side," Morgan says. "You are no longer solely responsible for the patient, but you have all these people involved in the care, all these people working together towards a common goal."
The only change Morgan would like to see is some standardized forms for reporting on patients which could be sent to the patient’s primary care physician and included in the patient chart.
"I think if we had that, it would be a perfect program," she says. "If you have the chance to participate in something like this, or even to start planning a program like this in your community, I’d say go for it."
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