How Optimizing Nurses' Roles Leads to Better Patient-Centered Care

Although the Patient Protection and Affordable Care Act includes pilot programs for various payment methodologies, there is still a great deal of uncertainty around payment reform overall. Without question, however, the overarching movement is toward better quality, lower cost care,  and a payment environment where providers are compensated for outcomes.

What financial leaders need are good examples of how to move hospitals from the current healthcare model of care to the future outcome-based model. Creating a patient-centered environment is an excellent place to start.

Syed Salman Ali, MD, a medical oncologist and hematologist, operates Fauquier Health Hematology/Oncology Center in Warrenton, VA. Since joining the staff of Fauquier Health last year, he has worked with the hospital to create a unique infusion center that emphasizes continuity of care through a patient-centered approach and by optimizing his nursing team's skills.

Greg Bengston, vice president for development at Fauquier Hospital, explains that in 2007 the hospital identified a need for a cancer center.

With the nearest treatment center for the community nearly an hour away, the hospital proposed a joint venture between Fauquier and its competitor Prince William Health System to build a radiation and oncology center. Not long after, the Cancer Center at Lake Manassas opened. With the success of that facility, Fauquier Hospital began to look for other service line opportunities. An oncology infusion center fit the bill, but any facility would have to fit Fauquier's patient-centered culture of care.

The patient-centered approach was a part of the culture at Fauquier Hospital, a designated Planetree facility since 2007. Planetree is a model of personalized care that is all-encompassing, from the design of the physical environment to the welcoming of family members as part of the healthcare solution. Millions of dollars had been invested in the hospital; now the oncology center and its caregivers needed to reflect the same approach.

"We started to look for free-standing space for the center, but because of our Planetree status, the structure had to be patient-focused," says Bengston. That meant when they looked at existing structures the organization needed to factor in how much would need to be altered to accommodate the needs of patients.

For instance, some studies show that natural light (as compared to fluorescentlight) promotes a sense of well-being for oncology patients. But not all the structures and spaces under consideration had enough windows to provide sufficient natural light.

So the hospital decided to build Dr. Ali's office alongside a new oncology center using existing space available at the front of the hospital. The location would fit several needs: it would meet the environmental design structure Fauquier Hospital wanted and it would provide links between the patient and the hospital and Dr. Ali and the center.

Ali, who sees patients in his office and also in the hospital, appreciates the synergy.  

"The infusion center patients see me as I go through the office and I see them. Even if I don't have an appointment with them, there is a certain psychological impact on the patient of knowing that the physician is a constant presence in their care," says Ali. The continuity of the patient's care, Ali explains, also comes from the team approach the center has achieved through outreach.

For instance, a patient who undergoes breast surgery meets with Ali to decide on postoperative treatment options. The nurse is in the room with Ali and is part of the treatment planning process. The same nurse works with the patient as she begins infusion treatments, and the nurse calls the patient at home between appointments to address any concerns. If there is any problem or question with a patient in the infusion center, Ali is accessible and a nurse can fill him in quickly. Ali is certain that this extended care has reduced hospital admissions. Through the phone calls and regular interaction with the patients, the nurses can detect difficulties early on, instead of waiting until the patient arrives for a regular appointment.

"The nurse plays a supportive care role and they keep me plugged in," says Ali. That means keeping tabs on how the patient is reacting to the potentially toxic treatments and ensuring the patient is able to maintain his or her quality of life throughout the process.

"They play navigator for the patient and that makes a difference. My nurses tell me when a patient is having a bad day or a good one. … So when a patient comes in for a follow-up visit, I know everything that's happened since the patient was last in. We want to do everything we can to keep our patients out of the hospital," he says.

And they have; nurses have caught potentially dangerous situations early on through their constant contact. If a nurse learns through a contact call that a patient is having a reaction to a treatment, the nurse can ask the patient to come to the outpatient center right away. Moreover, by catching any problems in the early stages, Ali explains that his practice is able to give the patient fluids and other treatments on an outpatient basis and avoid a hospital admission. "We don't want them to go to the hospital, we want them to go home," he says. 

The financial benefit of that isn't lost on Bengston's organization, either. "From a dollars standpoint … managing this as outpatient is cheaper to our system then managing it inpatient. And, certainly from the patients' standpoints, they are definitely happier," he said. 

Though Ali has only been operating the practice for a year, the system has begun tracking positive results. He was projected to have 72 new patients in his first year and he currently has 132. Being able to take on that patient capacity so rapidly while still maintaining a very personal approach to care is exactly the goal Ali and Fauquier were striving for. And, patient satisfaction scores are beginning to reflect that — for outpatient special procedures, satisfaction climbed from 83.9% in 2009 and 2010 to 84.5% in the first six months of 2011.

"What makes our program work is we make sure no one falls through the cracks," says Ali. "The team approach to each patient and listening to each patient's needs and situation means we can get them through the treatment … and maintain their quality of life. I think that's what makes this practice unique."

Dr. Ali's model of care is a good example of how using nurses to their fullest potential offers the opportunity to provide better patient-centered care. It also offers two other financial benefits:

1. It frees up the physician's time to see more patients, which in the current fee-for-service reimbursement structure allows for more billable charges.
2. It prepares organizations for the future reimbursement structure of pay for performance based on outcomes. 

If you haven't started the transition away from a fee-for-service model of care, Fauquier Hospital and Dr. Ali may offer a good option. Applying this outreach approach with some of your smaller service lines may be a healthy first step.