When communicating with MDs, less can be more
When communicating with MDs, less can be more
Streamline communication to reduce readmissions
It’s Murphy’s law in action: If you are trying to complete an important project, the phone will never stop ringing. That was the case in one cardiologist’s office in Watertown, NY, where office staff fielded a constant stream of non-emergency questions from home health nurses at Jefferson County Public Health Service.
When Jean Heady, RN, MS, CsC, director of patient services at the agency, heard the complaint, she knew she had to find a way to cut the unnecessary communication. "We knew we had to improve our communications with the physicians, and to do that, we had to connect with the gatekeepers at those offices," she says.
Heady took her best clinical nurse, Ginger Hall, RN, BSN, and made her quality improvement coordinator. "We had to hire another clinical nurse," Heady explains, "but I would have been adding staff to handle increased patient loads anyway." Together they came up with a new policy that put Hall in charge of gathering all the questions and funnelling them to the doctor. (See policy and procedure, p. 77.)
A year later, the program has spread to three physicians’ offices, and there are plans to start it in three more this spring, says Hall. There have been concrete benefits, too: faster response to questions, less time on the phone for the nursing staff at the agency and the practices, more referrals, and even lower hospital readmission rates for some of the patients involved, Hall says.
Initially, Heady and Hall met with a nurse from the cardiologist’s office. "We had to find out what information they needed from us in order to expedite decisions," says Hall. Together, they came up with a flow sheet that outlined a patient’s vital signs and left space for nurse commentary.
Each nurse fills out a chart for patients involved in the program at each visit. These are passed on to Hall, who reviews them herself. Weekly or twice weekly in some cases she goes to the physician’s office to review the charts with a nurse. Interventions are suggested and new orders given. This information is then passed on to Jefferson County Public Health Service staff.
The commentary section of the flow sheet is vital to the program’s success, says Hall. "It lets me tell them more than whether the patient is compliant or not," she says. For example, a patient may not be taking the appropriate medication. "But that could be because they can’t afford it," she explains.
When the doctor has additional information, he or she is better able to order changes or suggest interventions that will improve compliance and, in the long run, keep the patient healthier, says Hall.
If a nurse has an immediate question, Hall is in charge of relaying it to the appropriate physician. She spent a day in the office with the cardiology nursing staff, and was given access to some of their assessment tools. That training, plus a year’s worth of experience, has allowed her to take on some of the decisions previously reserved to the physician’s office staff.
When she does have to make a call to the office, they know it is important enough to merit immediate attention, she adds.
Some hesitation, then appreciation
Heady says the program has run smoothly from the start. "The doctors and nurses here recognized a need for better communication, so they saw us as saviors," she says. Some home care nurses, however, were less enthusiastic at first.
"The nurses had to give up a certain amount of control, and that was hard," says Hall. In the end, however, they recognized that they didn’t have to work as hard to get answers to questions. "I think they really like the program now."
Along with faster response to questions, there have been other benefits, says Hall. The cardiology office had its staff provide some inservice training to the Jefferson County Public Health Service staff. The inservice helped the public health staff better assess patients particularly those with congestive heart failure.
The three offices currently involved in the program are pleased with its success, says Hall. "We started out with 15 patients from the cardiology practice," she says. "Now we have 38."
There are about 70 patients involved. Hall says approximately 20 of them are new referrals resulting from the practices’ pleasure with the agency.
The three practices account for a quarter of all the patients at Jefferson County Public Health Service, but other patients also have benefited. "I think unnecessary communication with all offices has declined," Hall says. "We use more forms now than we used to."
Heady says the program could help solve other ongoing problems, although she has not studied this yet. "We identified that for both physician and hospital referrals, we would often get information on what medication the patient was taking only to find on home visits that it wasn’t so," Heady says. Such misinformation leads to a lot of unnecessary communication between Heady’s staff and the physicians. "If we work more closely with the offices and the patients, we have fewer errors of that type."
The biggest indication of success is the assurance from the cardiologist that hospital readmissions are down, says Heady, although she cannot yet say by how much. But there will be further proof of success later this year. Starting in June, the agency will be looking at hospitalization rates as part of the OASIS project, she explains. "We are going to look closely at whether rates from the offices involved in the project are lower than other practices. We are really excited about the potential for proving success."
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