Published in the July 2013 issue of Today’s Hospitalist
FACED WITH PATIENTS GETTING SICKER and a hospitalist team getting bigger, the hospitalists at Our Lady of the Lake Regional Medical Center in Baton Rouge needed help. But after trying various combinations of medical assistants, nurse practitioners, physician assistants and licensed practical nurses, the group came to a key realization.
What hospitalists needed was not a physician extender, but someone to take care of the host of other details that get lost in the shuffle.
“As the group grew, the clinical extension of the doctor became less important than the clinical logistics,” says Richard Slataper, MD, medical director of the hospital medicine service at the 750-bed hospital. The service, which grew from five hospitalists in 2000 to 32 today, needed providers who understood the clinical side, but who could also handle patient flow through the hospital and resolve any obstacles that got in the way.
The solution was to replace midlevels with RNs who function as clinical care coordinators. Their job description is basically “problem-solver”: part social service provider, part medical manager and part discharge planner.
Tasks include calling in prescriptions so patients can pick up medicines on their way home, arranging transportation for patients after discharge and helping patients make follow-up primary care appointments.
Coordinators also handle the team’s paperwork, from forms for nursing home admissions to durable medical equipment approval. They keep track of the preferences of multiple primary care physicians for specialists and post-acute care agencies, maintain current admit-discharge patient census lists, and assist with quality measure performance and documentation.
And coordinators perform discharges of complex patients, saving unit nurses a lot of time. They also make post-discharge calls to patients to sort out problems that could lead to a readmission.
Working as “coordinators of the coordinators,” as Dr. Slataper calls them, team nurses connect the hospitalists’ plan with primary care providers, chronic disease care clinics, insurers, specialists, home health providers and nursing homes, among others.
“The nurses,” he explains, “are efficiency experts who improve flow by better coordinating existing resources.”
After 15 years of refining the program, the upsides are clear. The model saves money on staffing, with each nurse costing about $50,000 less than a midlevel. Team nurses free up unit nurses to better handle their duties, making it possible for hospitalists to see more patients. And they take many of the pages and calls with logistical questions that would interrupt physicians.
The coordinated care that results is key to the hospitalists’ impressive stats: Thirty-day readmission rates are between 8% and 9%, while risk-adjusted mortality is half of expected. Length of stay for patients with team nurses averages 1.6 days less than other medicine patients. And emergency room bed holds plummeted 100% once the nurses began expediting discharges and coordinating with central bed control.
How it works
The hospitalists liken working with an experienced coordinator to working with an outstanding intern who never rotates off service.
With the average hospitalist patient taking between 15 and 20 medications for example, it makes a difference when a clinical care coordinator asks, “How are you taking this med?” instead of just going through pill bottles, Dr. Slataper says.
“That’s not a ding on the ER nurse,” he adds. “Medication reconciliation is a process, not an event. Patients and families come in with insulin pens, inhalers and other meds throughout the hospital stay, and clinical care coordinators are simply better positioned to achieve clarity. If we hope to deliver better service, we frequently have to drill down to get a better picture of what’s going on.”
Each nurse is assigned to one of 12 physician teams, with each team handling a daily patient census of about 16. (Each team has one physician.) Both physicians and nurses work 12-hour shifts beginning at 6 a.m. But while physicians are on service for seven consecutive days, nurses rotate every three or four days. That way, nurses know the patients and can facilitate a transfer to the next physician, and vice versa. At this time, coordinators don’t work on night teams or bridge shifts.
Team members each carry a phone for their service, allowing hospitalists and team nurses to stay in contact. In the morning, the teams review their patients and make assignments for the nurses. Throughout the day, the team separates and comes back together, sometimes rounding together. The team nurse also accompanies the physician to the ED for admissions, with medication reconciliation on admission a key role.
Finding the right fit
Because team members work so closely together, the service convinced the hospital administration that the hospitalists needed to hire their own nurses, rather than having nursing in charge of their hiring. Dr. Slataper notes that the hospital administration saw the advantages of a hybrid nursing model, which has a foot in the physician practice and another in the hospital nursing world. Team nurses report to a nursing supervisor, who reports to Dr. Slataper.
New hires receive a two-month orientation, working with an experienced nurse and getting feedback from individual physicians. They usually remain on the same team week to week, but occasionally switch due to staffing issues. Having adequate staffing is key because nurses from an agency or pool nursing won’t have the training to step in on a short-term basis.
Those who fill the job need to be able to adapt. Dr. Slataper suggests looking for nurses with between three and five years experience in hands-on patient care, preferably in an ICU or acute medical unit. Top candidates are those who are patient-centered and self-starters.
“They need to be willing to do whatever it takes to advance the patient’s care,” he says, “whether it’s clinical or clerical.”
Will it work for you?
Having a team nurse may not work for everyone, Dr. Slataper notes. A smaller group might be able to use geographically-based resources instead to be more efficient. A small but expanding group might do well with midlevel providers. But within larger groups, it pays to have “someone to connect the dots” he says, especially if hospitalists each have to cover more than six units.
What started as a cost-effective solution for the hospitalists at Our Lady of the Lake turned into a model that works well for both the hospital and patients.
“We have delivered in terms of ER throughput, decreased mortality and high levels of quality metric performance,” Dr. Slataper says.
Those types of outcomes will be even more attractive under value-based purchasing. “Anything that helps with that is worth taking a look at,” Dr. Slataper says. “It’s situation-specific, but it’s certainly helped us.”
Paula S. Katz is a freelance health care writer based in Vernon Hills, Ill.