Post 1
Professor and Class,
• How does your facility promote interprofessional collaboration during times of patient transitions?
Our hospital-based home care agency operates within an Integrated Delivery System and is the feeder for four hospitals. Our agency is currently in a pilot program for post open heart patients. After identify a high rehospitalization rate in our post CABG population, our home care collaborated with our hospital’s heart center and local cardiothoracic surgeons to create a Cardiac Rehab program. The collaborative process included our rehab director, nursing director, BSNs, physicians and the CVICU to establish protocols and standardized post-op evidence-based care in the home (Schub& Walsh, 2017). The goal of this program was to decrease rehospitalizations in the pre and post-surgical patients transitioning from the acute care setting to the home setting and decrease the barrier of the nurse trying to get orders from the surgeons. When the transition time point occurs, the MD determines if the patient is better served in rehab or home. When a patient is referral is received in our intake dept and identified as a ‘Cardiac Rehab’ patient this client is assigned to a core team of nurses, HHA, MSWs and therapists who have received special cardiac training.
• What is the role of the nurse in patient transitions?
The nursing focus transitioning from the acute care setting to decrease the risk of decline going from one setting to another. The homecare RN focuses on sternal precautions, wound care, all medications with attention to cardiac medication, disease process education and prevention of rehospitalization. A strategic interprofessional team member is the physical therapy component which teaches strengthening the heart and body. “Collaboration with our peers and our interdisciplinary team is also a critical component in best outcome measures” The RN case manager collaborates the services appropriate to meet an individual’s need. These services can include any or all of the following: CNAs, PT, OT, ST, MSW, and RN.
Teamwork and communication are crucial to patient outcomes. Home care field clinicians are not in the next room or down the hallway but driving alone miles apart. Each clinician communicates with handoff reports in one centralized document directly attached to the patient’s chart. In this forum, concerns regarding safety, patient decline or progress, achievement toward patient-centered goals are entered from everyone who engages with the patient. The expectation is for charting to be done in a patient home and with web-based documentation. This allows anyone, from any location, to evaluate a patient’s current status. The RN case manager must be able to monitor the progress of the patient, hold team conferences to identify patients at risk, and identify ongoing needs. When timepoint milestones occur, the RN uses the interprofessional input, critical thinking and his/her assessment to request orders for continued home care versus discharging to patient self-management with MD follow-up and/or an outpatient setting.
• What gaps can you identify in this process related to quality of care?
One of the major gaps I can identify related to the quality of care and patient outcomes is patient compliance. It is important to identify the reasons for non-compliance in our patients. Patients with capacity have the right to self-determination. If they choose not to engage in their health care with the behavior changes needed to maintain health, such as stopping smoking or following a diabetic diet, they have every right to do so. However, if the reason for noncompliance can be identified as situational such as financial limitations (cannot afford meds), cultural misunderstanding, transportation restrictions or medical illiteracy, the RN can arrange a variety of services to address these needs. For example, an MSW can problem solve financial issues, arrange bubble packing meds, enroll in medicine grant programs and arrange transportation. Cultural issues can incorporate the professional medical interpreter as a team member and the diabetic can be enrolled in ongoing diabetic teaching classes offered in the community.
Gaps are only areas waiting for solutions, several disciplines may see one patient and each offers critical contributions to create a customized care plan for a client. Effective problem solving and open communication within the team is essential to filling the ‘gaps’ and increase the likelihood of successful patient outcomes.