Care Coordination Nurses: Teamwork across the Continuum
Care Coordinator Mike Randazzo began discussing discharge planning with patient Roberta Gatzke and her family the day after her surgery for a brain tumor.
The morning after Roberta Gatzke had surgery to remove a large brain tumor, Mike Randazzo, BSN, RN, CCN, joined her family at her bedside to review her care plan and begin the discussion about transitioning care at discharge. Randazzo named a few rehabilitation facilities near Gatzke’s home in Central Massachusetts and in the Boston area, leaving them with a promise to return with more information.
“I’ll connect with a speech therapist and find out what’s available through your VNA,” Randazzo told Gatzke and her family to conclude his visit, the first of many during her stay on Tower 10C.
See a photo gallery of care coordination nurses at work.
Randazzzo is one of approximately 50 care coordinators at BWH. Care coordinators are registered nurses who are part of every patient’s care team, working closely with patients and families, physicians, clinical staff nurses and others to ensure patient care is well coordinated across the continuum. They carefully manage transitions for patients, plan payment for care and monitor patients beyond discharge.
“Care coordinators perform a balancing act by optimizing the available resources for patients to ensure the best possible outcomes while minimizing the burden of that care for them and their families,” said Joanne Hogan, MS, RN, director of Care Coordination.
Across the Continuum
Care coordinators at BWH work side by side with patient care teams in the Tower, Connors Center for Women and Newborns and the Shapiro Center. Care facilitators fill a similar role in the Emergency Department collaborating with ED clinicians, Admitting Department staff and patients and families. The role of care coordinators is expanding in ambulatory care, especially primary care where they help manage care for high-risk Medicare patients.
Other care coordination nurses provide insurance support and lead the diagnosis-related groups (DRG) assurance program making sure BWH submits clinical documentation that accurately reflects the intense and comprehensive care provided by all BWH clinicians. Their work requires extensive collaboration and teamwork with many BWH clinicians, compliance and finance staff, and government and private payers to insure appropriate reimbursement.
Since they focus on the entire continuum of care at BWH and beyond while keeping an eye on patients’ health insurance coverage and family resources, care coordinators are uniquely positioned to help improve safety in care and system efficiencies. Care coordinators have helped to reduce the length of stay safely and efficiently for many patients, better manage high risk patients in the community and plans are in place to help primary care practices with their highest-risk Medicare patients in a new CMS demonstration project. These care coordinators will assess patient needs, coordinate services and improve access to care across the continuum. The expertise of care coordinators is essential to succeed under health care reform.
Within a decade of its inception, the Department of Care Coordination was touted among the nation’s best by the University HealthSystem Consortium (UHC), an association of academic medical centers and affiliated hospitals that share data to develop best practices. UHC examined the impact of care coordination on patient care and clinical and financial outcomes. After analyzing performance measures within patient-level data at 28 participating organizations, the UHC highlighted three hospitals that consistently performed at the highest levels, and BWH was among them. BWH performed well in a number of the critical success factors, including interdisciplinary focus on coordination of care, active management of majority of patients (BWH care coordinators manage 100 percent of inpatients), beginning discharge planning early, developing practices to reduce length of stay and clinical program development with post-acute providers.
Care coordinators played a leading role in advanced care planning that helps reduce length of stay in Orthopedic Surgery. In what started as a pilot program, Care Coordinator Wilma Frieson-Gaskin, BSN, RN, CCM, began contacting patients prior to admission for knee replacement surgery. During that initial contact, assessment is made of patients’ clinical, social and financial status, discharge plans are developed, insurance coverage for related care and timely access to post-acute care is planned.
This pilot pre-admission discharge planning program for patients with knee replacements has resulted in a decrease in the average length of stay from four days to 2.8 days. Now, this system improvement is expanding to patients with hip replacements.
“The advance leg work eliminates a lot of anxiety patients have about discharge because it’s reassuring for them to know where they’ll be going after discharge,” Frieson-Gaskin said.
Around the World
Planning for a safe and timely discharge can be challenging. In December in Thoracic Surgery, Ann Higgins, BS, RN, planned an international discharge, sending one patient home to King Edward Memorial Hospital in Bermuda. “We provided a lot of support for the family, made sure there is a physician at the hospital in Bermuda who was available to care for the patient and helped make flight arrangements for an air ambulance,” Higgins said.
The Thoracics team sees many out-of-state and international patients, and that means the care coordinators interact with rehab facilities, insurance companies and visiting nurse agencies from other states and countries. But whether the patient is from Boston or Bermuda, the role of the care coordinator does not change.
“Our role is very proactive as we collaborate with patients, their families and the rest of the care team to ensure timely provision of hospital care and a safe and timely discharge,” Higgins said.
Staff nurse Daria Mlynarski, BSN, RN, OCN, and care coordinator Carol Orrico, RN, BSN, discuss a patient’s care plan on Tower 4C.
Often, BWH care coordinators teach the rest of the care team about what resources are available to specific patients. At the request of neurologist Tracy Milligan, MD, care coordinator Diane D’Olympia, RN, meets with the department’s new class of interns each year to review case management, insurance coverage plans and post acute services.
“It’s always a surprise when they learn what’s covered and what’s not covered, especially when we care for such a wide variety of patients with varying levels of insurance coverage,” D’Olympia said. “They don’t teach that in medical school.”
Presentations at national and local meetings is also part of the role. Christine Dutkiewicz, RN, MSN, CCM, nurse manager in Care Coordiantion, presented the department’s work on follow-up monitoring calls to high risk patients after discharge at the Case Management Society of America annual meeting in Phoenix. The calls are now documented by care coordinators in the LMR and represent progressive efforts in the field to increase patient safety and reduce re-admissions. Carol A. Gleason, MM, RN, CRRN, CCM, LRC, BCPC, who is the chairman of the Case Management Society of America Public Policy Committee, and Carol Ann Orrico, BSN, RN, care coordinators in the Bone Marrow Transplant Unit (BMT), in recent months presented their work at conferences held by the National Institute for Case Management in Boston, the Case Management Society of America in Phoenix and the Case Management Society of New England in Worcester.
“There’s a high level of interest in how we manage our BMT population because we have a higher volume than most, and care coordination plays a leadership role on our interdisciplinary team,” said Orrico. “Patients receive their transplants here, and then they are cared for within their community.”
Knowing Patient and Family
In BMT, care coordinators provide extensive financial screening and care management using evidence-based guidelines pre and post transplantation, intensive inpatient assessment, planning and discharge teaching. For BMT patients, additional responsibilities include making sure insurance authorization is in place for patients’ expensive medication regimen and that patients understand their medications.
“Three days before I was leaving, that’s when Carol made sure I knew what medications I’d be taking and when,” said patient Robert Sullivan of Rhode Island, one day before his December discharge.
In addition, Orrico makes sure patients understand that changes must be made at home in many cases since patients’ immune systems are compromised. “All rugs, drapes and blinds need to be cleaned, silk flowers disposed of and there’s no more sleeping with pets,” she said.
Discharging patients to a clean home is not always an option for patients of care coordinators in Medicine. Lynn Oliver, RN, CCM, Nancy Kelleher, MSN, RN, and Pia Young, BSN, RN, see many patients who are homeless and elderly, who often present to the ED with addictions, psychiatric diagnoses and “anything under the sun.”
“Our goal is to make sure the patient is well-served when they’re here, and when they leave,” said Kelleher. “But putting all the right pieces together can be challenging.”
Elderly patients typically do not want to be discharged to a rehab facility because they feel like they are being sent to a nursing home, but that same patient may not have enough support to return home. When patients have limited or no resources, the care coordinators negotiate the system to begin the process of enrolling them in Mass. Health. Patients at highest risk after discharge receive a call from a care coordinator within two days of discharge to assess clinical status and care in the community. In addition, for difficult placements, the team has forged positive relationships with the Barbara McInnis House, a medical shelter, and the Boston Center, a Partners HealthSystem skilled nursing facility.
“We need to connect the dots and know the resources and our patients.” said Young. “To do this job, you need to care for and respect the patient and family, bring strong clinical and analytical skills to the team, know non-acute and community provider capabilities, leverage insurance benefits and be resourceful for the patient.”