The nurse then enters that data into a health information technology system that generates for the nurse and others an evidence-based plan of care that incorporates all of the individual patient's chronic conditions. The nurse gets feedback on that plan from the patient, family, and primary care physician, "with the idea that if everyone contributes, then everyone will own it," he said.
"This is all in the way of just setting up the system: Once it's set, the nurse, working with the physician, then monitors these patients, proactively, every month," he said. The nurse doesn't "wait for the patient to get sick and show up in the office or the emergency department."
"All this is part of these monthly contacts, and, over time, the idea is that the patient [and] the family [become] more involved in self-care. At the same time the nurse is monitoring how they're doing," he said.
The nurse also may wear the hat of a coordinator. Since many of these patients are seeing eight or ten different doctors and lots of other healthcare providers during a typical year, the physicians those are "on different wavelengths. They're not communicating with each other. So the nurse uses this care plan that's developed as a communication tool to make sure everyone knows the same plan, even with updates."
The nurse also "provides support for family caregivers," realizing that they're the "unsung heroes" of chronic care. "They're the ones doing all the work in the background, with no acknowledgment, no training, and certainly little reward," he said.
Better Care Transitions
Today's system of providing long-term and community care is a "disorganized program that's patched together," said Bruce Chernof, president and CEO of the nonprofit SCAN Foundation. "The single most difficult time for a patient, [and] the single greatest risk is when you have a transition of care."
"It's not getting into the hospital that's hard. It's not the move from the emergency room to the hospital bed. That is one is the easy step," Chernof said. "The single most challenging step is from a [hospital] floor bed back into the community."
"I think one of our challenges today then is to think beyond just the medical tools that are a part of that transition but also the social tools that are part of that transition," he said.
A "thoughtful investment" there "can actually lead to a meaningful transition—one that's about quality of life, one that's about personal and individual self determination, and one that's also about quality of health."