Discharge Planning Advisor:

Slash hospitalization, lengths of stay for elderly

Geriatric nurses manage high-risk patients

By case managing high-risk elderly patients, Carle Clinic Association, PC, in Mahomet, IL, has shortened lengths of stay and improved care for targeted patients.

The population served by the Partners in Care program includes 2,000 capitated Medicare managed care beneficiaries who are at high risk for mortality, functional decline, and increased use of health care resources.

Utilization reduced

Since its inception in 1998, Partners in Care has dramatically reduced the utilization of health care resources for patients in the program. For example, patients in Partners in Care were hospitalized for a total of 1,721 bed days per thousand per year, compared to 4,162 bed days per thousand per year among a similar population not in the program.

Program participants were hospitalized 433 times per thousand per year, compared to 858 times per thousand per year for patients not in the program. And Partners in Care patients visited their physicians 13.2 times a year vs. 11.8 visits for those not in the program.

Carle Clinic Association is a multispecialty physician-owned practice with 290 physicians in primary care and medical surgical specialties. The practice is part of a health care system that includes a hospital, HMO, and other service companies, such as home health, pharmacies, and durable medical equipment suppliers.

The Partners in Care program received the Models of Excellence in High-Risk Patient Management award from the American Medical Group Association, in Alexandria, VA, and New York City-based Pfizer Inc.

Nurse case managers, called Nurse Partners, are the linchpin of the Partners in Care program, says Tuni Miller, RN, MS, Community Nursing Organization program manager.

The primary care physicians provide geriatric care and serve as team leaders. Nurse Partners actively monitor the patients. The nurses visit the patients in multiple venues, such as their homes, the hospital, or the nursing home, in addition to the clinic. They give the information they gather during site visits back to the primary care physician.

"This really helps with the ongoing support of the patient population. It helps the patients understand what is happening, what kind of treatment and recommendations their physicians have; and it helps the patients implement the recommended treatments," says Cheryl Schraeder, RN, PhD, FAAN, who heads the health system research center.

More attention given to frail patients

When patients are healthier, fairly self-sufficient, and have an active lifestyle, contacts are minimal. Patients who are frailer receive a comprehensive assessment to determine all their risk factors, as well as periodic assessments and visits. For example, the Nurse Partners keep a close watch on blood sugar levels, cardiac signs and symptoms, and weight for patients with congestive heart failure.

"Early detection can ward off serious acute episodes that land the patients in the hospital," Miller says.

The Nurse Partners work with patients, families, and physicians to help the patients maintain a healthy status so they can stay at home. They teach patients self-management and better ways to take care of themselves, and help them manage chronic conditions. The Nurse Partners telephone the patients at regular intervals, again depending on the health status of the individual. For example, the healthier patients may receive a call only once every six months. Patients who have just had an acute episode may be called once a week.

"It ebbs and flows," Miller says. "The Nurse Partners use their clinical judgment to decide how frequently the patients should be contacted. We also encourage them to call us if they have any questions or concerns."

What makes the Nurse Partner program unique is that it covers the acute care, home, and community settings. When a patient in the program is admitted to the hospital, the Nurse Partners work with the hospital case coordinator (formerly known as discharge planners) to provide information and help plan for the patient’s discharge.

The Nurse Partners coordinate any services that are needed after discharge and follow up after the patient returns home. The Nurse Partners often work collaboratively with people in the hospital, the home health agency, community organizations like the Office on Aging, and the physician’s office. "One issue with elders who have multiple needs is hooking them to appropriate services such as Meals on Wheels," Schraeder says. "Partners in Care really helps to provide continuity, monitoring, and support for a person with complex care needs."

Each nurse manages the patients of specific primary care physicians. There are about eight nurse partners, each of whom supports patients from five to six primary care physicians, spread out in clinics throughout the Carle Clinic Association treatment area.

The Nurse Partners are coordinated by a nurse manager and program developer and are assisted by care assistants, most of whom have worked in community agencies. Care assistants answer the telephone, take care of some administrative tasks, arrange for services, such as a homemaker service, and do some telephone monitoring, checking in with the patients and alerting the Nurse Partner if the patient needs to make an appointment.