One nurse provides hands-on care, plus CM
The wound care center at Presbyterian Hospital of Plano (TX) takes a holistic approach to patient care by assigning each patient to one nurse who provides hands-on care and case management. "We found that providing all aspects of patient care and case management was a really good change for us. The nurses have expressed more satisfaction, and we believe we provide better patient care by taking a holistic approach," says Kathy Zeller, RN, BS, director of the wound care center, who adds that wound care case managers typically aren’t found in the outpatient setting.
The case management piece is unusual in the outpatient setting. The outpatient wound care case management program has paid off in outcomes that have improved steadily, Zeller adds. In 2003, the hospital’s healing rate was 96%. This year, it exceeded 97% in the first quarter and was 100% in the second quarter. "It has to do with having a good team that works together well," she says.
The staff at Presbyterian Hospital’s wound care center all are registered nurses, with the exception of office staff and a nursing assistant. Nursing staff all are cross-trained to handle both wound care and case management. "Everyone knows the whole case management philosophy. They can pitch in and take care of patients’ needs, document on the chart, and handle all of the patient coordination," she says.
The RNs provide the wound care and work as case managers for their patients, coordinating home health services, durable medical equipment supplies, transportation issues, and making sure the patients get their prescriptions filled. "They get into the entire realm of case management, including documentation and medical necessity questions as they arise," Zeller says.
Zeller joined the center in 1998. In 2001, she decided to involve all the nurses in the wound care center in case management activities. "I felt it would work better if everyone was trained the same way to provide the full level of care," she says.
Each nurse case manager handles all the patients of the physicians to whom she is assigned. The case manager accompanies the physicians when they see the patient and work with the primary care physician on any subsequent issues. The nurse case managers make sure that everything the physician orders is carried out, that the patients get scheduled for the tests in a timely manner, and that the physician and patient are notified of test results.
The wound center runs 10 half-day clinics at Presbyterian Hospital of Plano, one all-day clinic in Allen, and one half-day clinic in Flower Mound each week. The clinics are staffed by physicians in individual practices, among them a vascular surgeon, plastic surgeon, and a podiatrist. The case managers typically cover patients in one to three clinics. The rest of the time, she works as an intake nurse or a wrap-up nurse in other clinics, providing the patient education and making sure the patients understand what they need to do at home.
When patients are referred to the wound care center, intake staff handle the precertification or authorization process and send the patient a four-page detailed assessment form. The nurse case manager accompanies the physician on the preliminary examination. "The physician and case manager are a team. They go from patient to patient during the clinic. The nurse case manager is the primary contact for the patient," Zeller says.
The nurse case managers give their patients business cards and encourage them to call them with any questions about their care at home. The case manager also is available to the home health nurse or other providers that may be caring for the patient. The patients come every week for the first four weeks and call the nurses if they have any questions. The nurses follow up on biopsy findings and other medical reports. If a patient has to be admitted to the hospital, the nurse case manager organizes the admission.
The average healing time for most patients is 10-12 weeks. Some heal in a few weeks, and others visit the clinic over a longer period of time. Some patients with chronic problems are in conservative care and come in every four to six weeks to make sure their wounds aren’t getting worse. The wound center has a vascular laboratory to evaluate patients with circulation problems.
"We offer one-stop care. Quite a few of our patients are elderly, and we make sure they don’t have to go all over the hospital," she says.
The hospital contracts with Curative, a Hauppauge, NY-based company that provides wound care management for more than 100 centers and maintains a database of more than 450,000 patients. The company provides the hospital’s wound center with a clinical pathway for the care of patients with chronic, nonhealing wounds, documentation support and other forms, policies and procedures, educational materials, and marketing materials that offer CME programs for physicians and CE courses for nurses.