A new approach to disease management for seniors
Sharing patient-centered data across continuum
With its mild climate and picture-postcard scenery, the rural Appalachian town of Hendersonville, NC, has become home to an ever-increasing number of elderly retirees. While that may be good news for the local economy, it’s presented an interesting challenge for case managers at Margaret R. Pardee Memorial Hospital, a 240-bed facility that’s become the major provider of health care services for the community’s burgeoning senior population.
Under pressure from managed care to manage this high-risk group cost-effectively, the hospital quickly realized it had to move away from its traditional focus on short-term episodic care and focus instead on long-term continuing care that addresses patients’ individual needs, says Barbara J. Hammer, RN, CS, BSN, MA, a gerontological clinical nurse specialist at Pardee. That meant fostering a greater level of cooperation with other clinical care providers in the community, such as primary care and home health.
Unfortunately, case managers at Pardee were finding it difficult to even share patient data with other units within the hospital system. Because each unit had its own admission database, and often its own distinct software format, patients were forced to provide the same information repeatedly as they moved from one unit to another. Some units even used different medical record numbers, and many did not use computerized records. In addition, much of the information that was gathered concerned only the acute care services provided.
"We felt it was important to get more patient-centered information that would give us a better sense of the whole person and his or her needs," Hammer says.
Care coordination prevents gaps in service
Without that kind of information, case managers at Pardee believed it would be almost impossible to identify ways to improve care coordination among the community’s providers. Gaps in service would result, and patients would continue to be shuffled through the local health care system by an expensive string of referrals.
To get the type of data Pardee’s case managers wanted, and to develop a system whereby the data could be shared first throughout the hospital system and then throughout the local health care community, Pardee secured a two-year grant from the Duke Endowment in 1992 that allowed it to construct an extensive relational database. Because Pardee had an existing relationship with Duke, which funds hospital projects throughout North and South Carolina, building interest for the proposal wasn’t difficult, Hammer reports.
"They were very interested in this project because it was something new and different, something nobody else in the state had really tried," says Hammer. She adds that when Pardee requested $170,000 for the project, "They said, We don’t think you’re asking for enough. If you need more, let us know.’"
Using FoxPro software, staff at Pardee developed a uniform system of data collection to be used by every unit within the hospital, including home health, emergency department, adult day care, and inpatient services. In addition to outcomes-oriented information, the system was designed to include financial records and information on a patient’s functional status and home environment.
To avoid the redundant documentation that characterized the old system, a task force designed the nursing admission forms to include three parts, with each part to be completed by a different unit within the hospital. For example, when an elderly patient visits the emergency room for the first time, the nurse there completes the first part of the form, which requires basic demographic information about the patient. If the patient is then admitted to the hospital, the nurse records the patient’s medical history, vital signs, and related information. An inpatient nurse would then fill in part three of the form, which takes into account details about the patients’ home environment, diet, and caregiver support.
"For example, one question that’s asked is how many steps there are in the home," says Hammer. "It’s that sort of thing. We wanted to know their risk factors and what was going on in their lives, not just what happened during their acute episodes." (See sample data collection sheets, pp. 137-138.)
System facilitates discharge planning
Staff in each unit are also able to access the database and call up any information that had been previously collected from the patient. The hospital’s case managers have found the database particularly useful in conjunction with Pardee’s 21 clinical pathways. Case managers can make more informed judgments regarding discharge planning when they have access to data concerning a patient’s risk factors and home environment, Hammer says. For example, if a patient’s record reveals that she has a history of falls and little caregiver support, the discharge planner might recommend a home assessment and additional physical therapy.
With its grant from the Duke Endowment now extended at least into 1998, Pardee is expanding its program to encompass Hendersonville’s entire provider community. The program may also grow to encompass other patient populations, including children. To accomplish that, the hospital is implementing a new software package, Senior Information Systems, developed in cooperation with Cincinnati-based health care information consultants Charles H. Mack and Associates. Using the new system, primary care providers and local home health agencies will be able to connect to the hospital’s database via modem. Local providers have just completed a two-week training course to learn the new software, and the hospital’s technical support staff are currently in the process of installing the system on computers at various offices throughout the community.
"There’s a long process we still have to go through," says Hammer. "And of course their people will have to sign confidentiality statements before they can begin accessing the patient information."
It’s unclear what will happen once Pardee’s grant money for the project runs out. Hammer expects that when that happens, the system will become community property, with each member of the network contributing financially to sustain the program. Alternatively, the hospital could continue to maintain and administer the program. "But it hasn’t come to that yet. We’re hoping we will get another grant to carry on for a few more years," she says.
[Editor’s note: For more information about Pardee’s data collection program, contact:
Barbara J. Hammer, RN, CS, BSN, MA, gerontological clinical nurse specialist at Margaret R. Pardee Memorial Hospital, Hendersonville, NC. Telephone: (704) 693-6522.
For more information or to request a grant application from the Duke Endowment, contact:
Eugene W. Cochrane, director, healthcare division, The Duke Endowment, 100 N. Tryon St., Suite 3500, Charlotte, NC 28202. Telephone: (704) 376-0291.]
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