Patient Satisfaction Planner
Community interventions aid self-care, prevention
Program has reduced LOS, readmissions
A program designed to prevent emergency department (ED) visits and readmissions for chronically ill older adults sends nurse case managers from Valley Health in Winchester, VA, into Virginia’s northern Shenandoah Valley to assist clients with special health needs.
Over the years, data have shown that the initiative has decreased length of stay, ED visits, critical care days, and readmission rates for the same diagnosis, says Lisa M. Zerull, MS, RN, program director for the Community Nurse Case Management program.
"We can see a decrease in actual charges over time," she says.
The program has a 100% satisfaction rate on patient satisfaction surveys for the past two years.
The Community Nurse Case Management program was developed as a way to better manage frequent fliers in the ED and the three hospitals served by Valley Health, Zerull says. The majority of the patients receive Medicare benefits, with an average age of 73. The patients live in the communities served by Valley Health and are mobile.
"We were doing a good job of coordinating inpatient hospital discharge plans and educating chronically ill patients for self-care. However, we were seeing some of the same patients coming back to the hospital again and again due to multi-system failure or challenges with medication management," she adds.
The three-hospital system hired its first case manager in 1993 after conducting a six-month pilot study that showed that nurse case management interventions in the community with mobile, chronically ill patients dramatically reduced readmissions and ED visits.
"The administration was willing to support the pilot program on a permanent basis after seeing the cost avoidance of more than $300,000 when compared to patient utilization of services six months prior to the Community Nurse Case Management program," Zerull adds.
The program now has three full-time nurse case managers carrying caseloads of 30 to 40 patients and averaging 98 home visits each month.
Program eligibility
Patients referred to the program are not eligible for home health, hospice, or long-term care but do have a range of chronic illnesses, and are medically frail with unmet social or nursing needs. To be eligible for the program, patients must have had two or more hospital admissions or three or more ED visits in a six-month period and are under the care of a Valley Health-affiliated physician.
Many of the patients have congestive heart failure or chronic obstructive pulmonary disease, with underlying diabetes, some behavioral health problems, or multisystem failures, Zerull says.
"These are not easy patients. They’re very complex and need a lot of care from nurses with a lot of experience," she says.
Referrals come through a central intakes process controlled by the Valley Health Home Health agency, which receives calls from physicians, social workers, RNs at one of the three Valley Health hospitals, home health nurses, and in some cases, caregivers.
"In 2001, when we instituted central intake, our nurses were afraid to give up control of receiving the referrals. The central intake process assures that patients receive the appropriate level of community care, either home health or nurse case management, and prevents any competition or duplication of services by our health system," Zerull says.
The nurse case managers coordinate the care of their patients, visiting in the home to promote wellness and self-care and encouraging patients to function as independently as possible in the community. The nurse case managers work independently but coordinate closely with the multiple physicians and community services that support their patients.
They constantly monitor their patients’ individual needs, help the clients set goals, coordinate community resources when needed, and educate the patient and family about early signs and symptoms of complications, medications, disease management, and wellness opportunity.
"The Community Nurse Case Management Program doesn’t operate under a medical model like home health. We do nothing invasive, and our services don’t require a physician’s order. Under the Nurse Practice Act of Virginia, nurses can assess, plan, implement, and validate without a doctor’s orders," she says.
However, because of regulations and the Joint Commission on Accreditation of Health Care Organization’s Home Care standards, the nurse case managers obtain physician orders for medication management, pulse oximetry, and oxygen administration, she adds.
When a case manager gets a referral, she makes an appointment to visit the patient and do an initial assessment focused on the patient’s physical, psychosocial, environmental, and financial or health care utilization needs.
She obtains baseline vital signs, along with weight and, in some cases, oxygen saturation levels in the blood.
"We want to take care of problems before they cause an admission. In the case of patients whose blood saturation level is dropping, we want to avoid full-blown respiratory distress," Zerull says.
Medication issues
The case managers see their patient weekly or biweekly. Because polypharmacy issues are a big concern with the targeted population, a primary focus of care is medication management, including drug assistance programs and helping patients remember when to take their medicine. The case managers sort the medications, filling almost 1,500 compartmentalized pill boxes to help patients understand which medication to take at what time.
"Whenever I make field visits with the nurses, I am amazed at the number of pills, primarily prescribed medications, that our patients take each day," Zerull says.
The average number of medications per patient, including over-the-counter medications is 13. Some of the medications must be taken three of four times a day.
"On a first visit, it’s not unusual to see a shoebox full of medication or multiple bottles spread out all over the counter. Helping the patient understand their medications and coming up with a workable plan is always a priority for the nurse case managers," Zerull reports.
The case managers refer the patients on a limited income to programs that can help them purchase their medications. "There are a lot of agencies that will help people with limited incomes, but they don’t make it easy for the elderly to access them. We know all those nuances and help them navigate the system," she says.
The program operates from a central office, but most case managers start their day from home, coming into the offices several times a week to touch base with each other.
Each case manager has a laptop, which she uses to upload information at the end of the day and download referrals and other information each morning.
The case managers work full-time and set their own schedule and are assigned to patients based on geographic location. They make frequent use of pagers and cell phones as they drive to see 30 to 40 patients each week.
On average, the case managers spend 20 to 40 minutes per visit with established patients. A new patient assessment usually takes one to 1½ hours.
"The program is free, and the patients love their nurses. We have the same nurse case managers seeing the same patients. Much of the success in terms of self-management and decreased utilization of unnecessary health care services comes from the continuity of the person as well as the continuity of care. This sets us apart from many health care setting where patients do not always have the luxury of having their own nurse,’" Zerull says.
Zerull, a master’s-prepared nurse with 20 years experience, coordinates the program on a part-time basis while pursuing doctoral studies at the University of Virginia.
She also provides leadership for the regional parish nurse network through which registered nurses promote whole-person health within their local faith communities. Services may include answering questions about medical or health issues, blood pressure screenings, health topic presentations, and helping parishioners find necessary primary care.
"The longevity of both programs supported by Valley Health as well as the overlap between the two programs enables me to truly make a difference in the level of wellness in our regional community. We fulfill our mission of serving our regional community by improving health’ each and every day," Zerull says.