Formal case conferences promote cohesion
Consultation program helps keep tabs on patients
Home care is a busy field. Nurses and other caregivers try to see as many patients as possible and keep up with paperwork. With so much to do, it is not surprising that a year ago there were few real case conferences at Good Samaritan Regional Health Center Home Health/St. Mary’s Home Care in Mt. Vernon, IL. Barbara Niles, RPT, clinical supervisor of rehabilitation services, worried that the 102 nurses, as well as the therapists, social worker, dietitian, and pharmacist, were not doing an adequate job of communicating about patients.
"I thought treatment was fractured," she says. "The more we grew, the harder it was to have a conference by catching someone in the hallway or parking lot and doing it piecemeal." State surveyors were also telling Good Samaritan that the original case conference format a piece of paper on which nurses wrote the date, who was talked to, and that data were discussed was inadequate.
"I felt patients would be better served if we coordinated our efforts," Niles says. So six months ago she created a program that shows signs of being a winner. Although no hard data are yet available, anecdotal information shows that the average length of stay for Good Samaritan home care patients is below the norm. Staff are finding it easier to meet documentation requirements, and state surveyors have praised the program as "being ahead of the game."
Regular meetings, specific briefings
The new format involves meetings twice a month in each of the five branch offices. A patient whose care involves more than nursing whether it is health aide care, pharmacy personnel, or one of the therapists is put on a master schedule by the nurse in charge.
Each person involved in the care of that patient must be ready to discuss the case at the meeting. "The discussions don’t restate frequencies, goals, or care plans," explains Niles. "They are to provide a snapshot of what is going on with that patient."
The end report includes information on what further action all parties need to take to meet the goals for each patient. Reports are then sent to clerical staff to type up, added to the chart, sent to the patient’s physician, and given to the patient and his or her family for discussion. (See sample final case conferencing report, pp. 32-33.)
As part of the conference, Niles made use of a trigger sheet developed by Good Samaritan earlier. (See sample trigger sheet, inserted in this issue.) The sheet is divided into six areas for various disciplines. For instance, under social work, there are questions for the nurse to ask about the patient’s financial needs and the patient’s ability to care for him- or herself. For mental health, there are questions on depression and drug abuse.
Each section has an acuity level. If a certain acuity level is met, it triggers intervention by another team member. For instance, if there is an unhealed wound, a poor appetite, or unexplained weight loss or gain, then the dietitian would be added to the case management team.
In formulating her idea, Niles sought input from her Continuous Quality Improvement Mini-Task Team a nurse facilitator, three other RNs from branch offices, herself, and a health aide. Over the course of three months, that team worked to develop a case conference program that would work for all involved.
This was harder than she anticipated, Niles admits, and some objected to the changes. "We’re all busy people, and the nurses want to be out seeing patients. Any time left over is spent doing paperwork. People felt that this was just an intrusion on the time needed to get things done."
Learning to be concise
At first, that’s exactly what it was, with some cases taking an hour to go through. "We had to help people learn to be concise and prevent the whole team from digressing," she says. Now, each case takes about 15 minutes to complete.
Niles gained acceptance from the staff by explaining how a more coordinated approach to patient care could get patients out of the system faster.
Once she formulated the program, Good Samaritan spent three months implementing it. There was an inservice for all supervisors, and Niles went to each branch office to educate the staff and oversee the implementation.
There have been some blips in the program. For instance, Niles says that initially, nurses forgot to add patients to the schedule. "We had to get supervisors to remind them to do this on a daily basis."
Another problem was how to involve the pharmacist and dietitian. Good Samaritan is hospital-based, and there are five home care offices. Niles says there was no way that the dietitian and pharmacist could attend every case conference. Instead, the conferences are scheduled, and these two staff members participate via telephone. The same holds true for the various therapists two each for speech, occupational, and physical therapy. Since they can’t be everywhere at once, they are included in discussions via telephone.
Audits show improved communication
Initial results have been positive. Niles says there is no formal data collection related to the program yet something she wishes she had put in place initially but staff say patients are getting off care faster. The quarterly case audits are also showing an improvement in the case communication area, she says. "Before, that was always a fault with us," she admits. And the records coordinator who is in charge of completing 485s says the final reports make it easier for her to document the goals on the required Medicare recertification forms.
"I think if I was doing this again, I wouldn’t fly by the seat of my pants," says Niles. "I wish I had looked for benchmarking information. I wish I had asked other organizations what they had done in this area. I would have put in place some way of collecting data to see how this affected our patients. But I think this is getting us nearer to better communication."
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