Published in the July 2015 issue of Today’s Hospitalist
MOST HOSPITALIST GROUPS are looking to improve their patients’ inpatient stay, care transitions and patient experience. The hospitalist team at Baylor Scott & White Hospital, Round Rock in Round Rock, Texas, has found a successful way to address those concerns: through their dedicated hospitalist team nurse.
While that nurse has plenty of responsibilities “setting up outpatient appointments, faxing discharge summaries to rehab and nursing facilities, making post-discharge calls to patients, and tracking quality metrics “one of the position’s most important roles is serving as an ambassador for the hospitalist group.
That’s according to hospitalist Trina Dorrah, MD, MPH, the physician director of quality improvement.
“The team nurse is a wonderful advocate for the hospitalist team,” Dr. Dorrah says. “She’s an experienced nurse, so she can answer most patient and family questions. She positively represents the hospitalists during each patient encounter, and she’s a good representative of our group to nursing and administration.”
As the group ambassador, the team nurse is charged with visiting each of the hospitalists’ patients by day 2 of their admission. (The group consists of 13 physicians and three physician assistants. The hospitalists cover about 80% of the patients in the 101-bed hospital.)
During a visit, the team nurse introduces herself and points out that she’s working with the specific hospitalist who’s treating that patient. Along with answering questions and educating patients about their diagnoses, she gives them a brochure on the hospitalist program, which explains what the hospitalists do and includes a group picture. If a physician is about to go off service, the nurse uses the brochure photograph to identify the clinician coming on for that particular patient.
And as the team nurse’s responsibilities have evolved, the hospitalists have asked her to focus on the patient experience. “One thing our team has really worked on this year is boosting our doctor communication scores,” says Dr. Dorrah. “We realized that one way to improve our patients’ perceptions of doctor communication is to have a consistent representative for our team both during and following a hospitalization.”
While team nurses are becoming more common in hospital medicine, the position at Baylor Scott & White, Round Rock is somewhat unique, in part because of the background of the person filling it.
A fluid position
The team nurse position was created seven years ago shortly after the hospital first opened. Kimberly Skaggs, RN, took the job in January 2013 “and, according to Dr. Dorrah, she is exactly the right fit. Because Ms. Skaggs was a charge nurse in the ICU for 11 years, Dr. Dorrah points out, “she came with a great deal of clinical experience and critical thinking skills. Both of those have been invaluable in this role.”
In addition, Ms. Skaggs says that the long ICU shifts were taking a toll on her and her young children. The fact that the team nurse job was Monday through Friday, 8 to 4 was a big draw.
“It’s very fluid and a catch-all position,” says Ms. Skaggs. She tracks data for the group, including daily encounters and readmissions.
She also handles some clerical tasks including obtaining outside hospital records and assisting with prior authorizations. She follows up on pending labs and test results post-discharge, and she does a lot of patient education, especially for new congestive heart failure and diabetes patients.
And on her daily rounds, every new hospitalist patient is given her business card and told to call her with any questions or concerns once they leave the hospital. (Hospitalists working weekends give their patients her contact information.) Many of the post-discharge calls she receives are about problems with medications.
“A patient may get to the pharmacy and find out that a medication costs $400, which the patient can’t afford,” says Dr. Dorrah. “The patient will call Kim who alerts us, and we’ll make a substitution. If we tried to put that on the primary care physician, it may take several days, but we can fix it immediately.”
Dr. Dorrah points to another big advantage of having a team nurse: providing continuity across hospitalist schedules.
“We need a consistent person for our patients,” she says, “and because we’re a rotating service, we need someone in place to ensure that things don’t fall through the cracks.”
When she visits patients at the bedside, Ms. Skaggs says that she doesn’t have to spend as much time now explaining who and what a hospitalist is as when she started.
“We have a fairly small medical community and we also have a health plan,” she points out. “A lot of patients are very familiar with the service and how it works.”
Typically, she explains, the face-to-face visits take between five and 15 minutes, but some last as long as an hour. “The physicians often don’t have that kind of time to offer.”
The hospital has seen its HCAHPS scores related to physician communication rise, and Dr. Dorrah gives Ms. Skaggs and her advocacy of the hospitalist group credit for that. As for readmissions rates, Ms. Skaggs notes that she sits on the hospital’s readmissions committee. But she points out that those rates have remained stable.
“What we’ve basically found is that some readmissions just cannot be prevented,” she says, adding that the community has used multiple resources to help patients get and stay healthy. “Those resources don’t always succeed as hoped.”
What has made a difference, however, is a county program she helped set up. At discharge, case managers refer patients who are at high risk of readmission to an EMS program, which is funded by a federal grant.
“Our county EMS program now has community health paramedics who go out to see patients who are either high risk or have frequent hospitalizations,” Ms. Skaggs explains. The EMS service follows heart failure, COPD and pneumonia patients for 30 days, making home visits.
“They also take a few of our high-risk diabetes patients,” she points out, “if they have any of those other diagnoses.”
Back to rounding
In addition to meeting with patients by day 2, the plan is for Ms. Skaggs to also meet with all patients on the day of discharge. So far, she hasn’t been able to work all those visits into her schedule.
But the hospital is looking to fill a new position, that of a care transition coach. That new hire could take on some of the work that Ms. Skaggs currently does to reduce readmissions.
“Because I took on some tracking of quality data for the hospitalist team, I’ve gotten farther away from patient rounding,” she points out. “The team would like me to get back to that aspect of my job.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.