Student program may improve quality of care
Student program may improve quality of care
HealthLink’ used for nonhomebound patients
The Visiting Nurses Association (VNA) Inc. of New Orleans, has developed a unique program that provides a continuum of care for home care patients who no longer qualify for Medicare home care services, but still need some assistance in order to prevent rehospitalizations.
Called HealthLink, the program is offered free to patients and is not costly to the home care agency because it’s provided by student nurses.
"Our mission is to assist clients to promote good health and to control their disease and to help them develop, maintain, and use their family and community support system," explains Katherine France, RN, MN, executive director.
When the VNA started the program two years ago, managers thought it would reduce hospitalizations, but might result in more patient referrals to home care services, France says.
Instead, the program has worked so well in preventing problems that only two patients have needed referrals for home care services, and rehospitalizations or emergency room visits also have been prevented, France says.
"Have we generated more Medicare patients as a result of the program? No, but that just goes to show how good the students have been doing, and it’s a wonderful community resource that helps us do what we’re supposed to be doing in keeping people healthy," France says.
Here’s how the program works:
• Establish relationship with nursing college.
The New Orleans Visiting Nurses Association has established a relationship with the Louisiana State University Medical Center’s nursing department so that the school’s professors help to operate the HealthLink program. The school’s bachelor’s degree nursing students must complete a community rotation, which fits in ideally with the VNA’s HealthLink program, so this is offered to students as one option.
"The university faculty members review all documentation with us, and we have an RN coordinator and an LPN who also work with HealthLink," France says. "We also have duties descriptions for senior nursing students, plus a confidentiality agreement they must sign."
The VNA’s clerical employees answer all incoming HealthLink calls and enter HealthLink patients into a computer database, as well as make copies of all forms used by students and faculty members.
The agency’s licensed practical nurse (LPN) assigned to HealthLink is responsible for conducting phone interviews every two weeks to patients and completing a questionnaire for the RN coordinator and student nurses to use in planning patient educational and health screening needs. The LPN also may visit patients under the RN coordinator’s guidance, and the LPN is supervised by the HealthLink RN coordinator.
The HealthLink RN coordinator is a registered nurse who supervises all aspects of the program, including providing assistance in assessing patient’s needs, contributing to patients’ care plan, and evaluating care plans and outcome measurements. Also, the RN coordinator provides orientation and job training to students, university faculty members, and nursing service personnel.
• Develop protocol.
HealthLink has three different service levels once a referral is made. (See story on VNA’s HealthLink mission and procedures, p. 82.)
The first is a telephone call made by VNA office staff. They contact HealthLink clients once every two weeks and follow a telephone triage protocol.
"Every week, we make a telephone call to them to find out how they’re doing and whether their living arrangement has changed," France says. "We ask if they have all of their medications and we make sure that they know what their medications are for, including side effects, food and drug interactions."
Next there is a profile visit, which is the initial evaluation visit that is done biannually with a comprehensive assessment. Students, accompanied by faculty members, conduct these evaluation visits and obtain all the necessary information about the client.
The last service level is the maintenance visit, which is in response to what is discovered during the profile visit or through a weekly telephone call. The student nurses make the maintenance visits in pairs, so no one is ever alone in the home. Student nurses assess patient’s needs, implement a plan, and evaluate outcome measurements. (See nursing student’s duties list, above.)
A client might be an 80-year-old woman who needs to be reminded daily to take her medicine. Otherwise, the woman is independent. So HealthLink will place those daily calls, and if other problems are discovered then the agency will send a nurse out to evaluate the woman’s situation.
• Have students conduct assessments.
Students work for the agency two or three times a week, traveling in pairs to client homes. During school sessions, the VNA might have as many as eight students working for HealthLink each day.
The assessments are designed to take a thorough look at the client’s living situation and the client’s ability to be independent. If a student discovers that a patient needs something, such as a cane or walker, then the student will talk with the HealthLink coordinator about the need, France says. (See story on student nurses learning about home care, p. 84.)
"This teaches students how to do a full assessment in the home, including assessing physical, emotional, and spiritual aspects," France says. "They ask clients about whether they are attending a church or have a support group, and they’ll also assess the home environment to make sure it’s safe."
However, if the student finds that a patient has had serious problems, such as falls or injuries, then the agency’s director of nursing also will get involved to evaluate the situation, France adds.
"The VNA coordinator will contact the family and say there is a problem and that the client needs to be paid a home care visit by a nurse, or the patient will need to see a doctor," France says. "That evaluation can be a Medicare or Medicaid visit or be paid by private insurance."
• Provide follow-up to students’ observations.
"Students have discovered so many potential problems, many of which they could handle alone," France says. "Many times, elderly people are very confused, so when they get a new medication, they continue to take the old one, and may end up in the hospital due to an overdose. When student nurses go into the home, they have the patients bring out all of the medications they are on and let them know if there are some medications they are no longer supposed to be taking."
Also, students have helped to avert medical emergencies among diabetes patients by talking with them and finding problems that needed to be corrected before the patient’s diabetes went out of control, France adds. "The patient will ask the student what he or she should do, and the student will say that the patient needs to go see the doctor."
Other times, students will identify problems that can be resolved by having a home care nurse visit the home.
To make certain that clients gain the most from the program, the agency teaches students how to gain patient buy-in to HealthLink services.
"I tell student nurses all the time that they may want to go in there and do great things, but if the client doesn’t want them to do it, it won’t get done," France says. So students are taught to inform clients that they will visiting the home for X amount of weeks, and then they ask the client what the client hopes to have accomplished by the end of that time period.
Clients might say they want to learn all about their disease, or maybe they want reading material or someone to read to them. Students have helped patients understand their prescriptions by reading them the pamphlets about side effects and drug interactions, France says. "Especially in this area, students often find that the reason people don’t take their medications correctly is because they can’t read."
• Make schedule to cover student holidays.
The only drawback to a community service such as HealthLink is that is dependent on the schedules of nursing students, and during holidays and school breaks there will be no coverage.
The VNA provides the service year-round, so during the summer break, VNA staff provide the visits, although they may visit patients fewer times than would the students, France says.
Typically, the agency relies on the telephone calls to clients to assess their need for a home visit and to make sure they are following through on health care plans, she explains.
"Sometimes, the patients have already been seen under Medicare or another insurance provider, but they still need to be monitored, and so we’ll go out there to see what’s happened," France adds. "Often, they just need to be reminded about when their next appointment is, and right after they go to the doctor, we call them to let them know that we’re here if they need anything or if they don’t understand something their doctor said."
• Katherine France, RN, MN, Executive Director, Visiting Nurses Association Inc., 2475 Canal St., Suite 248, New Orleans, LA 70119. Telephone: (504) 822-1477.
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