Critical Path Network

Acute care NP helps community-based MDs

Initiative speeds throughput, improves quality

When patients of community-based physicians are ready for discharge from Chesapeake (VA) Regional Medical Center, they no longer have to wait for their physicians to come to the hospital and write discharge orders.

The hospital has hired an acute care nurse practitioner who works out of the case management department and collaborates with two community physicians to manage the care of their patients while they are in the hospital.

Hiring the acute care nurse practitioner was part of the hospital's initiative to improve the quality of care for patients, decrease the length of stay, and increase patient throughput, says Roxana Ballinger, RN, BBA, CCM, director of care management for the 300-bed hospital.

"We saw a need to be more efficient and more seamless in our processes and to get the length of stay down even further," she adds.

Having the nurse practitioner on staff saves a tremendous amount of time for the care management staff and nursing because she is on site and can complete orders, dictate discharge summaries, expedite tests, and answer questions in real time, Ballinger says.

"The nurse practitioner is in-house and following the patients of these two physicians and collaborating with them on their patients' care. These doctors' volumes are high so that in the past, nursing and case management would have to leave a message and wait hours for a return phone call if something came up with the patient. Now they're getting answers in real time," she explains.

Docs with high volume targeted

The two general medicine physicians targeted for the initiative admit a high volume of patients and their patients have a higher average length of stay than similar patients being treated by other physicians, Ballinger reports.

"Because these doctors are in private practice and they're in the office all day long, their utilization of services isn't optimal and management of their patients is much more difficult. It's not that the tests and discharge wouldn't happen without the nurse practitioner, but it might take longer because the physicians are busy with the patients in their office," she adds.

For instance, if the physicians make rounds after their office hours and order a test at 5 p.m., it's not likely to be completed until the next day, often delaying the discharge.

The hospital has a hospitalist program but not all of the community physicians want to turn their patients over to a hospitalist, she says. They are general medical physicians in individual practice, and they want to remain that way.

The nurse practitioner joined the staff in June. The hospital pays her salary and benefits. The initiative has been so successful that the hospital has plans to extend it to the patients of other general medicine practitioners.

"The success of this initiative shows that there is an opportunity for the hospital and the physicians to collaborate for a win-win situation. The doctors get help in managing the patients more efficiently and in a more timely manner, and the hospital benefits because it frees up beds for other patients," Ballinger says.

Before hiring the nurse practitioner, Ballinger approached the two physicians to tell them about her idea. She wrote up a business plan for the hospital and presented it to the two physicians, the hospital's medical executive committee, and the hospital administration.

"They definitely supported it. The physicians were glad to have help managing their patients. From a hospital standpoint, if the nurse practitioner can drop the length of stay of patients being treated by these physicians by a day over a year's time, it more than pays for her salary," Ballinger says.

The nurse practitioner works Monday through Friday from 8 a.m. to 4:30 p.m. Each morning, she gets a printout of patients admitted by the two physicians and reviews the list to determine which ones are new patients and which have pending discharges.

She collaborates with the physicians, either by telephone or in person, to determine what the patients are likely to need that day and who can be discharged. She talks with the physicians throughout the day and calls them to report at the end of her workday.

Pending discharges are her first priority.

Many times the physicians can't get to the hospital until late in the day. The nurse practitioner is able to discharge early in the day, freeing up the bed for other patients, Ballinger says.

The nurse practitioner reports to the case management department and works closely with the care managers and placement specialists, communicating through e-mail on a PDA.

"The case management department is the most logical place for her to be located. The case managers are unit-based and scattered throughout the hospital and so are her patients," Ballinger says.

NP works with care managers, social workers

At Chesapeake General, care managers are responsible for care coordination, discharge planning, and utilization review.

The social workers, called placement specialists, handle the rehabilitation, skilled nursing facility placement, adult home, and assisted living placements, as well as handling psychosocial issues.

Having the nurse practitioner saves the care managers from having to make multiple telephone calls and faxes to the physician office when patients are ready to be discharged, Ballinger points out.

If the care managers or placement specialist have a patient who is ready to be discharged, they call the nurse practitioner, who comes to the unit and dictates the discharge summary.

In the past, discharges to post-acute facilities were delayed until the doctor could come to the hospital to take care of the paperwork.

"The care managers and placement specialists often would have to make multiple phone calls to the ambulance service, changing the pick-up time, and to the nursing facility to arrange a time for admission. Coordination of care is so much smoother because we have a point person instead of having to go through the office nurse and finally speaking to the doctor," she says.

Another benefit is that the nurse practitioner is always available when family members have questions about post-discharge instructions or levels of care.

"She's available to talk with the family about discharge and work with the care manager and placement specialists to coordinate the discharge in a timely manner," Ballinger says.

(For more information, contact: Roxana Ballinger, RN, BBA, CCM, director of care management, Chesapeake Regional Medical Center; e-mail: