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APNs ensure patients move through the continuum

Nurses lead the care management team

Case management is a collaborative process at Edward Hospital in Naperville, IL, with advanced practice nurses leading a team that includes utilization managers, social workers, and staff nurses.

Having the advanced practice nurse lead the care management team helps ensure that patients receive optimal care in a timely fashion and move quickly through the continuum, says Patti Ludwig-Beymer, RN, PhD, administrative director for education and research at the 300-bed regional health care provider.

"From my perspective, after being in nursing for 33 years, advanced practice nurses can move the patients along faster because they have prescribing authority and can write orders, clearing the way for patients to be discharged in a timely manner," she says.

The hospital, which achieved the prestigious Magnet Award for nursing, has been using the practice model for more than 10 years.

"Advanced practice nurses are extremely knowledgeable about patient needs and patient care. Over the past year, as we have focused on the core measures data, the case management piece of the advance practice nurses role has increased. We believe that our hospital is forward-thinking and has the best-educated people possible providing patient care," she adds.

The advanced practice nurses have a collaborative practice agreement with physician groups that allows them to write orders and discharge patients from the hospital under the guidelines of the practice group under which they work. They collaborate with the treatment team on patient care and work with the utilization staff to monitor length of stay and documentation.

"The model is rich in dollars, but it's also rich in knowledge. The advanced practice nurses bring a lot of talent to the table, and they can move the patients quickly through the health system. They are well trusted by the physicians, who treat them just like a colleague," says Lynn Wagner, RN, MS, CNAA, administrative director for critical care and the medical-surgical units.

The advanced practice nurses are the frontline care providers for patients in the hospital. If the bedside nurse has a question or sees that a patient has a problem, she calls the advanced practice nurse on her team, who may order medications or tests or call in the cardiologist if necessary, adds Lynn Cochran, RN, MS, director of cardiovascular inpatient services.

"As a piece of their role, they serve as physician extenders. They can clinically manage the patients, write orders, and work with their physician partners," Cochran says.

All members of the care management team are in constant contact all day about the patients and the discharge plan, she adds.

"The utilization review staff are in frequent contact with the advanced practice nurse and the physicians to ensure that the patient is moving through the continuum smoothly," Cochran says.

Because they are in the charts and at the patient bedside all day long, the advanced practice nurses know from daily practice what the barriers are to getting patients through the system, Ludwig-Beymer says.

They serve on the team that examines ways to streamline the patient throughput process by ensuring that tests results are back in a timely manner and that patients with the potential to be discharged get a high priority on the list, Ludwig-Beymer adds.

The multidisciplinary team meets weekly to discuss patients who have been in the hospital for seven days and look for obstacles that need to be overcome for the patient to be discharged.

When a patient is ready to be discharged, the advanced practice nurses are on the floor and can write the discharge orders, eliminating delays in discharge, she adds.

The advanced practice nurses have worked with the rest of the hospital staff to standardize treatment regimes so that every patient is treated under evidence-based guidelines, Ludwig-Beymer says.

One advanced practice nurse works with the emergency department to educate the ED staff on patient protocols and to make sure that standing orders for cardiac and pulmonary patients are followed.

The advanced practice nurses are credentialed by Edward Hospital's internal medicine credentialing body.

The seven advanced practice nurses at Edward Heart Hospital have collaborative practice agreements with the physician groups that practice at the hospital.

"We have one big cardiology group that often has as many as 70 patients in the hospital. The advanced practice nurse can't see all of them, but between them, the doctors and the nurses see all of the patients every day," Cochran says.

The six advanced practice nurses who work on the med-surg floors have collaborative agreements with the highest-volume medical groups that practice at the hospital.

The nurses are assigned by unit for interdisciplinary rounds on some of the med-surg floors. They always are available to any staff member who has questions or concerns about a patient.

The advanced practice nurses are primarily employees of the hospital, with most of their salary paid by the institution. The heart hospital invoices the physician practice group for a percentage of the nurses' salaries.

In addition to managing patients in the clinical setting, the advanced practice nurses track patients who have implanted devices, are members of the hospital's rapid response team, and are involved in clinical research.