Kentucky hospital earns rep for continuum care

Good word of mouth draws patients

The Clinical Path Task Force at Ephraim McDowell Regional Medical Center in Danville, KY, has created a group of pathways that do more than pay lip service to the phrase "continuum-based" by involving a wide array of health care providers, including office-based physicians, rehabilitation therapists, and home health professionals.

For example, the institution's total hip and knee replacement pathway was developed between 1994 and 1995 by case managers working with a team that included physicians, orthopedic surgeons, and representatives from rehabilitation and social services. (See sample pathway, pp. 134-135.)

Patients are referred to the pathway either by community-based physicians or by patients themselves, says Judy A. Kuhns, RN, BSN, NHA, director of case management at Ephraim McDowell. "Patients come to us now because it's well-known in the community that we do pre-op teaching and the continuum of care for several procedures," Kuhns notes.

Once a patient's referred, the admissions nurse and the case management department work to draw up a schedule for each patient, typically four to six weeks in advance of surgery. The schedule includes the patient's name and telephone number, the planned surgery date, the physician, the name of the planned procedure, whether or not the patient is autologous, and the dates and times of the patient's scheduled appointments.

Once the schedule is made, the admissions RN checks with the patient and makes adjustments based on his or her availability. "We have younger and younger patients all the time having major procedures done, so if they work nine to five, then their appointment may be at five or six o'clock at night," Kuhns says.

The admissions nurse then sends the patient a follow-up note and a business card, along with instructions to page the admissions nurse before the first scheduled appointment.

All assessments done at first visit

Different disciplines within and affiliated with the hospital coordinate the patient's first appointment as well. Once a final schedule is hammered out with the patient, the schedule is sent to the disciplines via either voice-mail or e-mail. At the time of the patient's first appointment, the observation unit nurse calls representatives from these disciplines to let them know the patient has arrived. They then have 45 minutes to one hour to introduce themselves and perform their initial assessment. "Everyone comes to the patient. That way you don't have people coming and going at four different visits," Kuhns says.

Also at the first appointment, "we obtain copies of the patient's insurance card and insurance information so that we have everything for the patient to be pre-registered for the day of their actual major surgery," Kuhns says.

A preoperative chart is established, which is later merged with the chart for the major inpatient stay. Accompanying the chart is a checklist to be signed by surgical nurses and laboratory professionals. The checklist includes items such as the time the preoperative education video was shown, and when pre- and postoperative social services visits were performed. Rehabilitation services also assesses which exercises may be necessary for the patient postoperatively.

In addition, rehabilitation services evaluates the patient's equipment needs. "For instance, if the patient already has a four-prong cane or a walker at home, then that wouldn't be an equipment need for the future," Kuhns says. As part of the assessment, the patient is allowed to choose a medical equipment supplier. Following that, the case manager follows up with the insurance company to work through any problems.

How ready is the patient to learn?

Also during the preoperative phase, an education sheet tracks dates, times, "learning readiness," and family needs. "It evaluates the patient's response as to how they are able to verbalize, or they need reinforcement, or the family needs to be involved -those types of situations that bring the patient together as a whole along with their support system," Kuhns explains.

Several disciplines also play an active role in preparing for the discharge of the patient following the acute care stay, she says. These include physicians, social workers, the case management team, and rehabilitation. In addition, representatives from home health services perform an assessment prior to discharge. "So we are able to communicate both in writing - through the clinical plan of care - as well as on-site visits with the patient to assess what level they are," Kuhns says.

For more information, contact Judy A. Kuhns, RN, BSN, NHA, director of case management, Ephraim McDowell Regional Medical Center, 217 South Third St., Danville, KY 40422. Telephone: (606) 239-2336.