Published in the April 2005 issue of Today’s Hospitalist
An innovative program at Virginia Mason Medical Center is helping elderly patients answer a common question: When can I go home?
In March of 2004, the Seattle hospital introduced a new unit that focuses on the unique needs of elderly patients. The acute care for the elderly (ACE) unit, an idea that is just beginning to appear in U.S. hospitals, gives hospitalized seniors the care they need to get back on their feet quickly.
An important part of the ACE unit is a tool known as the “Ticket Home,” a message board that helps patients, their families and members of the health care team keep a close eye on the goals that are critical to a speedy recovery “and a timely discharge.
Because elderly patients tend to be complex, their discharge often hinges on resolving more than the one or two medical problems that landed them in the hospital. The “Ticket Home” message boards help patients and staff track the other key factors that will bring about discharge such as mobility, functional independence and level of pain.
The boards, which are part of every patient room in the ACE unit, provide areas for hospital staff, patients and their family members to write messages for each other and to ask questions about the patient’s progress. But more importantly, they help everyone understand what needs to be accomplished before patients can go home.
A new twist on an old concept
Message boards aren’t an entirely new concept at Virginia Mason. Other units in the Seattle hospital also have message boards where staff and patients can jot down questions and comments.
But the “Ticket Home” boards in the ACE unit feature some signifi cant differences that better serve the unit’s unique patient mix. Patients are eligible for the 23-bed unit if they’re 65 and older and have a medical diagnosis. Surgical patients are generally not admitted to the unit, and neither are patients who need telemetry services or are receiving chemotherapy.
The boards in the ACE unit are big “six feet wide by more than two feet high “so that older patients can read the type, even without their glasses. And while message boards are used in other units of the hospital, they are much more tightly integrated in the ACE unit. Virginia Mason designed the unit’s patient rooms around the white boards, mounting them on the wall at the foot of patient beds in the ACE unit to make for easy visibility.
The “Ticket Home” boards in the ACE unit are also structured and organize information using three sections.
The first part is a cork board where patients and family members can hang personal effects like cards and notes. This part of the board also contains a clock.
The second and biggest portion of the board uses large type to track patients’ progress in key functional areas. This section of the board, for example, lists goals like “I can feed myself” and “I can walk safely.”
The final portion of the board is reserved for comments from patients, their families and caregivers. Debra Beauchaine, NP, geriatrics services director at Virginia Mason, says this part of the board gets considerable use from both patients and staff.
Ms. Beauchaine notes that the boards provide a quick snapshot for patients, their families and the various members of the team caring for the patients. The blank sections in particular encourage all the groups to keep in touch “and on the same page.
“Nurses communicate with each other in terms of team issues, such as patients who are on a turning schedule,” she explains. “Everyone is aware of the care plan for that particular patient.”
Ms. Beauchaine says that families often use the boards to ask questions of physicians or other team members. Patients and their family members, for example, can ask when tests or procedures are scheduled or inquire about the results of a consultation. “One of the nice things that happens quite often is that families ask a question and a physician responds using the board,” she explains.
She also notes that patients and family members typically need little prompting to use the board, and that many write personal messages on the boards for their loved ones.
Ms. Beauchaine admits that she initially wondered how well a communication device that focuses on discharge “”Ticket Home,” after all, is the name of the initiative “would be received by terminally ill patients who may never return home. But she says that even that group of patients and their families seem to like the tool.
“I’ve seen them using the boards fully,” Ms. Beauchaine explains, “especially the part of it that’s blank. They fill it up with questions for physicians and nurses, information about preferences and likes and dislikes of the patient, when they will be coming in to visit, and who to call and when.”
Ms. Beauchaine says she particularly likes the boards because the information on them changes to reflect developments in the patient. “It’s all erasable,” she says, “so it’s meant to change as the patient’s plan of care changes throughout the hospital stay.”
Streamlining the discharge process
While the “Ticket Home” boards have improved communication between patients and caregivers, Ms. Beauchaine says they serve an even more important purpose: streamlining the discharge process.
“The idea is to help patients and family members understand what it is going to take to be able to be discharged home,” she explains. “You have patients who want to go home, but we may need to recommend a temporary stay at an extended stay facility for reconditioning. If people are having difficulty understanding that type of thing, the board gives us an opportunity to discuss functional areas and explain what patients can and can’t do.”
“Sometimes patients have achieved medical goals and they’re medically safe for discharge,” Ms. Beauchaine explains, “but functionally they’re not prepared to go home and be independent. This helps gives a visual story. You can point to the board and say, ‘Here’s the reason you’re not ready to go home.’ ”
She adds that the “Ticket Home” boards often serve another purpose: “For patients who are really goal-directed,” she says, “you can tell them that this is what it’s going to take for them to be discharged. They can use the board to set goals.”
Virginia Mason currently has no plans to study the boards’ impact on factors like length of stay, but Ms. Beauchaine says that’s not the point.
“We’re not saying that we’re going to guarantee a decrease in length of stay,” she explains, “just that we want to improve communication between the various members of the team and the patients, between the team members and the families, and among the team members themselves.”
“This is a way of making sure that in another visible way we are communicating the plan of care with the patient,” Ms. Beauchaine says. “We want it to be an open communication process.”