Roughly 5% of the patient population is complex. Those complex patients typically have a chronic physical issue (e.g., diabetes, renal disease, cancer) and a behavioral health issue (e.g., schizophrenia, depression, anxiety).
Although a small percentage of the patient population is complex, they account for more than half of healthcare costs, says Rebecca Perez, RN, CCM, CPUM, president and owner of Carative Health Solutions in High Ridge, MO.
The separation of physical and mental health services
Hospitals primarily treat patients solely for their physical ailments, ignoring underlying mental health problems. With no incentive for reimbursement, facilities often address a patient's mental health only as an afterthought.
However, an untreated mental condition can prevent patients from properly managing physical health, thus causing the patient to be readmitted to the hospital.
The debate over healthcare reform centers on the effort to reduce costs, and that means reduced readmissions. Addressing the needs of this small, expensive segment of the population could help curb healthcare spending.
"Case managers really are the best professionals when it comes to coordination of care and being advocates for patients, which is why integrated care is a perfect adjunct for what a case manager already does," Perez says.
Integrated care training
Perez is part of a growing movement addressing the mental health needs of complex patients by using an integrated care management model.
"The thinking is coming full circle again where we need to treat the patient as a full person and not just treat a disease," says Perez.
Perez and Roger G. Kathol, MD, CPE, president of Cartesian Solutions, Inc.?, work with the Case Management Society of America's Integrated Care Management Training Program to train case managers. Participants learn how to assess a patient's mental health as part of their interaction with complex patients. This enables case managers to ensure that the patient's care plan includes services that address his or her behavioral and psychological needs.
"Integrated case management is not necessarily designed for every patient a case manager touches," Perez explains. "It is designed to work with those that are the most complex."
Recognizing how this population's mental health contributes to their physical health goes a long way in preventing readmissions, improving patient satisfaction, and enhancing overall quality of care.
The chronic illness demonstration project
The New York State Department of Health is addressing complex patients with a chronic illness demonstration project. The project identifies patients that are most likely to be readmitted due to several concurrent medical conditions.
Hudson Health Plan, a provider of state-sponsored managed healthcare services based in Tarrytown, NY, partnered with Beacon Health Strategies, a company that specializes in assisting health plans and providers to meet behavioral healthcare needs, in order to participate in the project.
Hudson's new program, the Westchester Cares Action Program (WCAP), was designed to assist clients selected through the chronic illness demonstration project using the integrated care management model.
"We believe that good primary care will lead to prevention of ED visits and readmissions," says Sheilah McGlone, RN, CPUM, CCM, director of case management and utilization review at Hudson Health Plan and co-director of the WCAP.
The WCAP's case managers use the INTERMED-Complexity Assessment Grid (IM-CAG) tool to help evaluate complex patients. The INTERMED Foundation developed the IM-CAG tool to help case managers create a detailed profile of the patient and identify barriers in the following four domains:
Biological. Does the patient have any chronic illnesses?
Psychological. Does the patient have a history of or currently show signs of psychological issues such as depression, anxiety, or substance use?
Social. Does the patient have access to social support services? Does he or she have a stable living arrangement?
Health system. Has the patient had difficulty assessing services? Did he or she have a bad experience with providers?
The case manager shares the results of the assessment with the treatment team as well as the patient to improve coordination of care.
Case managers obtain information by conducting through interviews with patients. Based on their responses, a case manager assigns patients a score and a color designation. The colors correspond to the following categories:
Red is an area of extreme vulnerability that requires immediate action
Orange is an area of moderate vulnerability that should be a part of the treatment plan
Yellow is an area of mild vulnerability that should be monitored
Green is an area that requires no action
"The IM-CAG tool helps formulate a care plan based on priority levels," says Alan Boardman, LMSW, co-director of the WCAP from Beacon Health Strategies.
For example, if a patient is homeless, the case manager can make the "residential stability" field red.
The three-year demonstration project is still in its first year and is currently focused on assessing patients and developing care plans. Boardman and McGlone say they have not begun measuring the program's success. Nevertheless, they hope the project will help make the integrated care model the preferred method for handling complex patients.
Integrated care in action
Hospital case managers do not need to be experts in mental health to be effective in the integrated model, says Perez. She encourages case managers to become familiar with basic mental health issues and seek advice from experts when dealing with complex patients.
But in order for integrated care to work, case managers need to be willing to address behavioral problems when signs are apparent. For example, if a patient is not progressing through rehab as quickly as anticipated, perhaps depression or some other behavioral problem could be slowing the process.
Identification of the mental health problem is only the beginning of the process. "You can't just say [to the patient], 'You need to go get counseling,' " Perez says. Instead, case managers need to take the time to help the patient discover the problem as well as establish relationships with physical and mental health providers for better communication.
Hudson Health Plan tries to facilitate effective communication between hospital case managers and mental health providers as part of its demonstration program.
Some mental health providers may be hesitant to share information about their patients because of confidentiality concerns. In that case, tell the provider that you are not requesting detailed notes, just basic information that you can use to support the patients' needs, Perez says.
Although the reimbursement model does not lend itself to coordination between mental and physical health, a sharp case manager can make a big difference in the care of complex patients. The willingness to address behavioral health issues and their effect on patient outcomes will help case managers meet departmental goals and better serve their patients.
This article was adapted from one that originally appeared in the April 2010 issue of Case Management Monthly, an HCPro publication.
In 2004, our Professional Nursing Staff Organization (PNSO) sought to develop a formal, robust, and sustainable clinical research program for nurses at the University of Virginia Health System in Charlottesville. We recognized that to make research part of what we do, we needed to provide nurses with the tools to effectively innovate practice by conducting studies on topics important to them. In doing so, we believed we would further strengthen our evidence-based practice culture.
Although some suggest that conducting research studies is beyond the realm of bedside clinicians, we believe the opposite. Because essential questions emerge from practice, bedside nurses are perfectly positioned to both ask and answer the questions. To that end, we sought to develop a program for practicing clinicians that was rigorous yet practical. This thriving program is now in its fifth year and is described below.
Key components of the program
Central to the program's success is that it is led by a research director who understands the clinical environment, has successfully done clinical research, and who is a recognized clinician mentor. The key program components include concrete support of projects (i.e., unit and administrative support), mentorship and guidance of the research clinicians by the director, and a practical method that guides the clinicians through the research process from inception to completion, including presentations and publications, one step at a time.
Application to the program
A call for research clinicians (called research mentors, or RMs) is published annually via hospital intranet.
The call for applicants describes the elements of the program and, most importantly, notes that the role of the RM is to lead a unit-based research team study. No previous research experience or educational level of preparation is required for application to the program.
Applicants submit a short description (no more than one page) about why they wish to be an RM and also describe a unit project that they have completed from beginning to end. This is a key part of the application as we recognize that an individual's perseverance and follow-through are important predictors in ensuring the successful completion of a research project.
In addition to the clinician's application, we ask that the applicant's manager and administrator write a note of support for the applicant. These application elements are all sent to the director via e-mail; no other supporting material is required. Administrative support.
The PNSO office supports the research program by providing partial salary support for the director—and now also the assistant director who recently joined the program. In addition, the PNSO provides funding for statistical support on a project-by-project basis.
The participants who are selected as RMs are supported by their respective units. In reality, this requires little financial support given that the projects are all unit-based, carefully constructed so that they can be accomplished on the unit, and most learning experiences are provided one-on-one by the director as the research team progresses through each step of the research project.
The RM research process
Once accepted into the program, the clinicians attend a one-day in-house conference on clinical research program and process. The focus of the conference is to energize and inspire the clinicians, explain the RM role (to mentor and guide other team members), and formalize the participants' commitment to the program.
In addition, they are taught the process for leading the team, starting with how to develop a research question. A rough timeline is set—the projects generally take a full year to complete and a second year to present formally and begin the process of writing for publication.
Following the kick-off conference, the individuals move at a pace that works in their setting; learning is done one-on-one with each research step. Prior to each team meeting, which is usually accomplished during the course of a workday, the RM meets with the director to review the steps.
Following the meeting, he or she debriefs with the director about the meeting and also discusses the next step and the timing of that step. For each of these meetings, the director generally goes to the unit where the RM works, but sometimes the discussion is conducted by phone or even by e-mail.
Regardless of the method, the RM and director are in close communication throughout the process. Clinicians are busy, and time away from the unit is sometimes very difficult to accomplish. The program acknowledges this fact by making the process reasonable and doable.
The selection of a study is determined by each research team and is always a team decision. Generally, the team identifies multiple research questions, but before any are voted on, the director reviews them with the RM to eliminate those that may be unduly cumbersome, difficult, or not amenable to a design that will work well without sacrificing rigor.
The goal is to design and implement a study that is feasible in terms of the study population (i.e., accrual of an adequate number of study variables in a short period of time [three months], complexity of data collection, timing, and study design).
RMs are reminded that the studies are not dissertations, and to that end, the projects are somewhat narrowly focused and convenience sampling is often employed. In addition, all the projects are sent for review to our Institutional Review Board (IRB).
Although most of the projects are designed to be both expedited and not require a full written consent, they vary in complexity; teams that have previously successfully completed a project often design second studies that are a bit more sophisticated and complex than the first. A number of these "second generation" studies have been accomplished, and others are in process.
The majority of RM projects take a full year to complete, and once completed, the teams present the study findings formally at our annual "Evidence-based Practice Day" conference.
Following these presentations, and often simultaneously, the RM teams submit abstracts to local, regional, and national conferences. The process of writing for publication is quite a bit slower, but each project goes through the process with the director with the intention being to publish the work eventually.
Outcomes of the RM program
To date, the program has 38 active RMs. Although 44 clinicians have gone through the program, some anticipated attrition has occurred as some have left the institution, are involved in other focused professional activities such as school, or have left the program for personal or other professional reasons.
Thirty-four IRB-approved projects have been completed or are close to completion, and seven more are in process. The RM teams have presented more than 200 presentations at local, regional, or national venues, and more than 400 clinicians throughout the hospital are involved in these projects. Fourteen articles have been published; many others are in progress.
Most important to the program's success is that the study results are shared within the hospital and vetted through our professional practice mechanism for implementation. In many cases, the projects have been adopted for application in the units in which they were developed or for widespread use throughout the hospital. The program's sustained success has surpassed all expectations.
Where are we now?
The program will enter its sixth year in September. It continues to be extremely popular, and applications are numerous. In part because of its popularity, program applications were not accepted in 2009 because of the workload. Not only were many projects ongoing, but second generation studies were increasing as were requests for the director's time to guide those doing research outside of the established research program model.
In addition, writing for publication is a necessary and essential step that we wished to focus on, and the time and effort to do so is substantial. An assistant director was hired in September 2009 to help support the program growth and so that future program innovations and strategic planning for the next five years might be accomplished.
Conclusions
The PNSO research program is a user-friendly program that ensures success of the participating clinical researchers. Unlike traditional research programs, this program is designed to teach research to bedside clinicians; no previous research background is required.
Not only has the program resulted in the professional growth of the participating clinicians, but the studies have helped improve the care we provide our patients. In fact, the program has changed the way many clinicians think about evidence-based practice because it is an important, essential, and expected part of practice—and indeed, it is doable.
Suzanne M. Burns, RN, MSN, ACNP, CCRN, FAAN, FCCM, FAANP, is a professor of nursing, APN 2, and director of the PNSO Research Program at the University of Virginia Health System in Charlottesville.For information on how you can contribute to HealthLeaders Media online, please read our Editorial Guidelines.
The "silo effect" can be very damaging to a hospital system. It occurs when hospital staff members strictly focus on their function (e.g., social work, discharge planning, utilization management) and forget how their function influences other healthcare professionals. When this happens, communication between disciplines becomes very difficult.
When Grace Dotson, RN, MS, CMAC, CPUR, joined Greenville Hospital System (SC) as the director of outcomes management, the first matter she wanted to address was improving communication and eliminating the facility silos.
One example of the problem Dotson saw was that case managers spent their valuable time playing phone tag, waiting for e-mails, and searching the halls for coworkers. As a result, efficiency suffered. The average length of stay (LOS) at Greenville was high, and avoidable days were numerous.
Greenville needed a better system for communicating with staff members in other departments, so Dotson came up with a daily flash rounds meeting.
Not your typical meeting
The daily flash rounds meeting structure is simple: There is no structure. Dotson feels that the informal nature of the meeting makes it more likely people will attend and also makes the meeting quicker.
Keeping with the informal attitude, Dotson tells staff members to come to the meeting "with their sense of humor and their census."
Staff members who can attend include some of the following:
Utilization nurses
Case managers
Social workers
Well Vista (a medication assistance program for the indigent population)
Business office employees
Physicians (particularly hospitalists)
The meeting is early—10:30 a.m.—and quick, only lasting 15 minutes. "I like to compare it to speed dating," Dotson says.
Once in the meeting, attendees are free to roam around the room and mingle. They typically make small talk before asking for information about one of their patients. After a case manager tells a utilization nurse about a potential discharge, he or she can head over to the Well Vista staff member to talk about that patient's medications.
The casual atmosphere has also made it easy for new staff members to get to know colleagues. This face-to-face contact has now been incorporated into everyone's daily work flow at Greenville, and people enjoy it, Dotson says.
As a direct result of the flash rounds, Greenville has:
Met its goal for reducing LOS
Increased the number of patients referred to the Well Vista program by 50%
Improved timely delivery of the Important Message from Medicare
Tips to implement flash rounds
Initially staff members were not excited about the idea of another meeting. However, they now believe the 15 minutes spent at flash rounds have saved time overall.
If you choose to implement a flash rounds meeting at your facility, consider these tips for combating staff resistance:
Excuse: I can't attend because I don't have time.
Response: Everyone can spare 15 minutes out of their workday, hence the 'flash' title for these rounds.
Excuse: 10:30 a.m. isn't a good time.
Response: A time that is universally good for everyone does not exist. However, by 10:30 a.m., staff members have had the chance to return calls, print their census list, and participate in unit discharge rounds.
This article was adapted from one that originally appeared in the February 2010 issue of Case Management Monthly, an HCPro publication.
Ten to 13% fewer surgical patients in New Jersey and Pennsylvania would die if hospitals in those states had as many nurses as California law requires, according to a University of Pennsylvania study. The study of 1.1 million patients in 2005 and 2006 found that the nurse-to-patient ratios mandated in California could have saved the lives of 468 patients in New Jersey and Pennsylvania over a two-year period. Linda Aiken, who led the study and directs the Center for Health Outcomes and Policy Research at Penn, said improved nurse staffing likely could save "many thousands a year" nationally.
Originally introduced by The Joint Commission to the standards in July 2002, staffing effectiveness is the appropriate level of nurse staffing that will provide for the best possible outcome of individual patients throughout a particular facility.
When first introduced, hospitals were required to track two human resource indicators and two patient outcome indicators, track data, and determine whether the variation in performance caused by the number, skill mix, or competency of staff.
"Hospitals collected the data, nurse leaders looked for correlations, and no correlations have been found," says Susan W. Hendrickson, MHRD/OD, RN, CPHQ, FACHE, director of clinical quality and patient safety at Via Christi Wichita (KS) Health Network.
Hendrickson says even if hospitals did find what they believed to be a correlation between staffing and a patient outcome, when the information was examined more closely, it was not statistically valid.
Fast-forward to June 2009: The Joint Commission suspended these standards due to the debate of the results from across the country.
However, this suspension proved to be short-lived. In December 2009, The Joint Commission announced the approval of its interim staffing effectiveness standards for 2010.
The new standards will become effective July 1, and will remain in effect as The Joint Commission continues to research the issues of staffing effectiveness.
Interim standards at a glance
The first requirement affects LD.04.04.05, element of performance (EP) 13, and states that at least once per year, the hospital/organization must provide written reports on all system or process failures, the number and types of sentinel events, information provided to families/patients about the events, and actions taken to improve patient safety.
"In a broader sense, EP 13 ties staffing to outcomes and puts accountability at the leadership's feet," says Hendrickson. She suggests hospitals submit the reports to the board quarterly or monthly, rather than annually.
"Think about this: Every time a medical error occurs and you have to document it, this may be a long report for the board to get a grip on," says Hendrickson.
Rather than compile an itemized list of failures, hospitals should instead classify the events and report on them statistically.
"Sentinel events, you will want to try to discuss the events as soon as possible, and disclose general information to the board," says Hendrickson. "And if a sentinel event did occur, then disclose information on any action taken to prevent similar events."
In addition to EP 13, the new interim requirements affect PI.02.01.01, EPs 12–14.
EP 12 states that any time the organization has an undesirable event, it must evaluate its staff and their effectiveness. EP 13 states that if a negative trend in the staff is noted, a report must be provided to the leadership.
In EP 14, a written report of the identified issues must be provided at least once per year to the leadership in charge of the patient safety program.
"The organization needs to have a process or policy that speaks to this so the surveyor can review the information," says Hendrickson. "The Joint Commission believes that if you are not in compliance, this is an immediate risk to patient safety because there are few processes to intervene."
Now if an organization is cited for any staffing effectiveness, a short-term resolution is given, and the organization is required to come up with a solution within 45 days.
Turning to patient-staff ratio
In addition to the new interim standards, a more intricate part of staffing effectiveness under examination is the patient-to-staff ratio. However, California is no stranger to this because a staffing ratio has been imposed on all organizations in the state since 2004.
To meet the patient-to-staff ratio, many hospitals in the state used traveling nurses from all areas of the United States. By doing so, many of the new nurses ended up taking residency in California, skewing the numbers of the nursing shortage elsewhere.
Despite the additional nurses, the ratios between patients and staff were not always met.
"Meeting the ratio at all times was difficult," says Cyndie R. Cole, RN, MSN, CNO at the Ventura (CA) County Medical System. "Going from three RNs on the night shift to five RNs on the night shift added a tremendous cost, and then during the day shift staff were not used to being forced to take their lunch break at a specific time."
Over time, however, nurses managed to work together with the administration to come to a better understanding.
For this year, a set ratio for each unit in the hospital must be met at all times, with no exceptions. The patient-to-staff ratios for each unit include:
Critical care: 1:2
Neonatal ICU: 1:2
Postanesthesia care unit: 1:2
Labor and delivery: 1:2
Postpartum (moms only): 1:6
Pediatrics: 1:4
Step-down: 1:3
Telemetry: 1:4
Med-surg: 1:5
Specialty care: 1:4
ED: 1:4, 1:2, 1:1
"In the ED, the patient census is always changing, so three different ratios are set up," says Cole. "On an hour-by-hour basis, we are checking and making sure we are adequately staffed." To help with the ED's unpredictability, Cole developed two tools over a three-year period, to work together to help ensure that the patient-to-staff ratios are always met.
The first tool is an hourly census that requires the charge nurse to document the patients in the ED and those patients in the emergency room waiting area. By tracking the patients in the ED and those waiting, the tool helps determine when the ED census will be at its highest and helps the facility call more nurses to meet the patient-to-staff ratio.
In addition to the hourly census, facilities utilize an Excel spreadsheet that automatically determines variance in the ratios.
"This gave us a tool to show where our major hours of being under the ratio occurred, and allowed us to present to our fiscal people hard evidence the times when we need more nurses," says Cole.
The importance of staffing effectiveness
Staffing effectiveness is being addressed at a national level, with the possibility of all hospitals one day being required to meet a nurse-to-patient ratio.
"Staffing effectiveness in a hospital, meeting ratios, and meeting acuity plans is a day-by-day process," says Cole. "It is something we have all worked hard to do, but it is still not perfected."
Even with time, Hendrickson believes that it is still important for hospital leaders to look at staffing issues. "We need to understand how staffing affects outcomes, because we are all held accountable for patient safety," she says.
Most importantly though, Hendrickson says, it is necessary for organizations to develop the evidence for their own practices. "We need to work together in order to determine what practices will improve the outcomes. And then we have to spread that information across our profession."
This article was adapted from one that originally appeared in the March 2010 issue ofBriefings on The Joint Commission, an HCPro publication.
Flu shots are recommended for all healthcare providers, but fewer than half get vaccinated in a typical flu season. But by mid-January, 62% of healthcare workers had received a seasonal flu shot, though only 37% had been vaccinated against the H1N1 swine flu, the Centers for Disease Control and Prevention are reporting. In addition, 34.7% of healthcare providers reported receiving both vaccines.