Critical Path Network

Patient-, family-centered care helps decrease LOS

Information sharing, collaboration are key factors

By involving patients and family members in the treatment plan and discharge process before they are admitted to the hospital for treatment, the staff at Moffitt Cancer Center in Tampa, FL, within a five-month period of time decreased length of stay by almost two days and achieved a 7% increase in the number of admissions involving hematology patients.

On the medical oncology team, patient days were increased by almost 50%, a major improvement in patient throughput.

The facility's emphasis on providing patient- and family-centered care is a major factor in the improved patient throughput, says Linda Pearson Hodges, RN, MBA, CCM, ACM, CPHQ, manager of the case management department.

The hospital's 162-bed inpatient unit is at capacity all the time, with patients waiting at home to be called in for treatment, she adds.

The four cornerstones of patient- and family-centered care are: dignity and respect, information sharing, collaboration, and participation.

"We are working to incorporate those four components in every process we implement. We know that if we have this in place, we can improve clinical outcomes and patient satisfaction and increase throughput at the same time," Hodges explains.

As a National Cancer Institute Comprehensive Cancer Center, Moffitt treats more than 7,200 patients and records more than 252,000 outpatient visits a year. The hospital's blood and marrow transplant program is the largest in the Southeast.

"By collaborating and communicating with everybody involved, patient access, throughput, and discharge are so much smoother. It all boils down to having everybody on the same page, and that includes the treatment team, the patient, and the family," Hodges reports.

The case managers facilitate a lot of that communication and collaboration by educating the patients about the conversations they need to have with their physicians. Encouraging dialogue between the treatment team and the patients and family member is a must, she says.

"One of the biggest roles case management and social work have in this process is to push for rounds to occur with the patient, family members, physicians, social workers, case managers, and other appropriate members of the team. This allows the patients to know our individual roles, to know who to ask questions, and to understand that we are all talking about the same thing," Hodges says.

On the bone marrow transplant unit, the entire treatment team — physician, nurse, case manager, and social worker — conducts rounds in the patient room, talking to the patients and family members about their condition and getting their input on the next steps in treatment.

This ensures that everybody on the team and the patient and family are fully informed about what is going home and ensures that patients and family members don't have to track down several different members of the team to get questions answered.

"It's not really any different from what we should have been doing all along. In the health care arena, we have a tendency to decide what is best for the patients and to put patient involvement on the back burner. Patient participation is essential for a successful treatment plan and discharge," Hodges says.

In the bone marrow transplant program, all patients have a consultation with a social worker and a case manager before treatment begins. Then the entire treatment team meets to discuss the patient's treatment plan, including whether the patient's psychosocial needs and coordination of care needs are met.

"We have tried to implement a continual assessment of a patient's needs, including psychosocial needs as well as resource utilization needs," Hodges explains.

Participation is one of the key elements to making the patient- and family-centered care process work, she says.

"In oncology particularly, we tend to think we know what is best for the patient, but we cannot have physicians and the treatment team acting in a vacuum. The patient needs to be involved. If a patient is not participating in treatment planning and is not fully informed about his options, he may not make good decisions," Hodges says.

When a patient is receiving oncology care, it often takes more than one discussion with the family, physicians, and support personnel for the patient to feel comfortable making a decision, she reports.

Hodges tells of a patient who was set up for surgery but called to say he was having second thoughts. She arranged for the physician to call the patient and go over every option again. The patient ended up choosing radiation treatment.

"The first time patients come to the facility, they are stressed and fearful. The whole diagnosis and treatment process is overwhelming. We help them become informed so they can make better decisions," she says.

In the past, the physician would recommend surgery and the patient would just say OK, Hodges adds.

"Now we let them know that the treatment is their decision. The case managers and the social workers offer them the support and information they need, and we ask them to participate in the choices. They can go back and discuss the options further with the physicians if they want," Hodges says.

Patient- and family-centered care has had a huge impact on ensuring that patients are preparing to go home on the day they are admitted, she says.

"We know as case managers that we can tell patients in the hospital that they're ready to go home, but if the patient and family aren't ready to go, they don't go. Even the Important Message from Medicare tells them that if they don't feel they are ready, they don't have to go," Hodges points out.

By including patients and family members in the treatment plan and keeping them informed throughout their stay, they're prepared to go home when they're clinically ready to be discharged, she says.

In the past, case managers at Moffitt started discharge planning on the day of admission. Now the team starts looking at a patient's discharge needs in the clinic setting, before he or she is admitted to the hospital.

"We are looking aggressively at the patient's discharge needs before admission and making sure that the patients and family members are ready for discharge," she says.

For instance, since hematology patients have complex discharge planning needs, the case manager meets with them individually on admission or even in the clinic setting and discusses the treatment plans.

"We help them understand how they can be involved in the treatment decisions, look at caregiver impact, and determine what we can do at our facility vs. what can be done on the local level, and incorporate all of that into the inpatient experience. When there is better communication between the family, patient, and providers, it expedites patient throughput," she says.

For instance, hematology patients usually are discharged with multiple IV antibiotics and must either go home with home health services, receive them as an outpatient in their community or come back to Moffitt for infusion, a drive of several hours for many patients.

"The patient has a choice, and we respect that. We try to arrange what is best for the patient, but we don't know what their choices are until we sit down with the patient and family and discuss it," Hodges says.

If the case managers know in advance what the patients' preferences are, they can arrange for an oncologist in their home town to give them their medications. The case managers can collaborate with social workers in assisting patients in finding accommodations in Tampa if they choose to stay close for their outpatient treatment. That way, there are no delays in discharge and patients know what is going to happen when they go home, she says.

The goal of Moffitt's patient and family care initiative is to involve patients in key decision-making processes throughout the organization as well as making sure that patients undergoing treatment are informed about and comfortable with their treatment plan, Hodges says.

The hospital has created a patient advisory board to give the staff input in areas of operation. Patients sit in on planning committees and performance excellence committees throughout the hospital.

The hospital is looking at health care delivery from a patient and family member standpoint, Hodges says.

For instance, a team of patients has advised on ways to improve patient access to the facility. The hospital has met with a group of patients undergoing outpatient chemotherapy infusion to get their input on how staff can better prepare the patients for what to expect during treatment.

(For more information, contact: Linda Pearson Hodges, RN, MBA, CCM, ACM, CPHQ, Manager, Case Management Department, Moffitt Cancer Center; e-mail: Linda.Hodges@moffitt.org.)