CMs coordinate with home care on continuum path

Path includes provisions for home care visits

When Elkhart (IN) General Hospital launched its open heart surgery program last year, case managers recognized that establishing strong ties early on with home health care agencies could help provide patients with a cost-effective continuum of care and prevent infections and unnecessary hospital readmissions.

While outcome data are not yet available, anecdotal evidence suggests the program and its accompanying clinical pathway are accomplishing their goals on both the home health and hospital sides, say key personnel involved with the program.

The 350-bed hospital provides the full circle of cardiac services, including angioplasty and open heart surgery. The chief goal of the home health segment of the pathway is to prevent patients from returning to the hospital and to prepare them for outpatient rehabilitation. In addition, home health staff provide patients with emotional support and reinforce patient teaching on medications, nutrition, and exercise, says Cindy Bieber, RN, CCRN, cardiac rehab coordinator.

"It makes a significant and measurable difference," Bieber says. "I know from my own home health experience that if you weren't there to find a problem with post-open-heart surgery patients, the patients might not have called a physician until they were at death's door."

The home health visits also increase patient satisfaction and provide positive public relations for the hospital, says Shelby Morse, RN, hospital director of case management.

"Patients appreciate having a nurse visit them, someone who answers questions and helps them feel confident about their recovery," Morse says.

Here's how the hospital and its affiliated home care agency set up the program:

1. Assess need.

Elkhart has had an intensive coronary care unit, but for years the hospital only provided medical treatment for cardiac patients. "We used to transfer out any invasive cardiac procedures," says Susan Stack, RN, CCRN, coordinator of open heart recovery.

Then physicians and hospital administrators analyzed patient data and realized they were sending a lot of patients to the South Bend area and Indianapolis for angioplasty and open heart surgery, Stack adds. "Once they got the statistics, they realized this area would benefit from a heart program," Stack says.

2. Create pathway.

Hospital-based case managers and the cardiac care team, including representatives from respiratory therapy and physical therapy, developed a clinical pathway that tracks patients from surgery to recovery, post-op care to home health, and then to outpatient cardiac rehabilitation.

Hospital representatives also worked on the pathway with members of the hospital's home health agency to establish a continuum focus. "Our first attempt at a pathway with home care was a congestive heart failure pathway," Morse reports. "Some of the home care nurses had a tendency to want to write in many home health visits, so there was a lot of negotiation that went on about what was really needed and what could we accomplish most cost-effectively."

The final pathway allows for four visits. The first visit takes place within 24 hours of discharge from the hospital and lasts about an hour. The home health nurse assesses the patient's condition, including observing the chest and leg incisions, looking for signs of nausea and infection. Then the nurse reinforces instructions the patient was given in the hospital.

Home health nurses also discuss medication, signs and symptoms of infection, and fluid restrictions. They tell patients to check their temperatures and pulses regularly and record their findings. Patients are taught to keep a daily log listing the type and duration of their exercises.

The second visit occurs on the third day after hospital discharge. Nurses review the patient's exercise log and temperature log to make sure he or she is recording information correctly. Nurses also make sure patients are taking their medications correctly and have no difficulty tolerating medications. The third visit takes place on the seventh day after discharge. Nurses reinforce patient education by discussing the disease process and the importance of exercise, good nutrition, and proper hydration.

Pathway represents 'recommended' standard

Nurses make the fourth and final visit on the 10th or 14th day after hospital discharge, after the patient has visited the physician's office. Prior to this visit, the home care agency sends the physician information about the patient's progress. If the physician recommends any changes, the home health nurse makes these adjustments at the fourth visit.

Morse notes that the pathway and home health schedule were established only with the hospital's own agency. However, the hospital did send the pathway to all other privately owned home care agencies in town. "We told them what we were planning to do and let them know that the pathway represented the standard of care that we recommend," Morse says. "But really, it's up to them to decide whether to use the pathway or not."

3. Develop patient teaching tools.

Hospital and home health staff use one pathway, and patients are given another that covers three weeks of care, starting when the patients are first hospitalized. The 15-page patient pathway includes all the educational material they might need to understand their disease and its treatment.

Bieber says she created the patient pathway partly to help patients with their anxiety about what will happen next and what is expected of them. "It also offers encouragement throughout the pathway," Bieber says. "For instance, on Day Four, it states, 'Keep up the good work; walking makes you stronger and helps the healing.'"

The first page of the patient pathway explains why the patient is in the hospital and what will happen during each step of surgery and recovery.

"Also, before they go home from the hospital, we give them an activity work sheet," Bieber says. The work sheet includes information about how much walking patients should do each day and how to watch for symptoms of infection or other problems. It also includes a place for patients to log their heart rate.

For more information, contact Shelby Morse, RN, director of case management, Elkhart (IN) General Hospital. Telephone: (219) 294-2621.