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NPs bridge gap between discharge and first visit
Transition and palliative care benefit from experience
(Editor's note: This is the first of a two-part series that describe how two different agencies use nurse practitioners in their program. This month, we look at the two programs and next month, we will evaluate reimbursement for nurse practitioner services as well as how to hire nurse practitioners.)
Making sure that patients are properly assessed by referral sources before they are discharged from a hospital is a continuing challenge for home health agencies. There are many times a home health nurse arrives at the home for the initial assessment visit to find that the patient's condition and needs were not accurately described or that the patient is not appropriate for home care.
To address this issue Visiting Nurse Service of New York is piloting a program that has a nurse practitioner visit the patient at the hospital to perform a pre-discharge assessment to determine level of care needed following discharge and proper placement, says Joan Marren, RN, MEd. chief operating officer of the agency.
Nurse practitioners are not new to the agency. "We have nurse practitioners who work with our long-term, managed Medicaid patients but we saw a role for nurse practitioners in home care," says Marren. Not only were discharge assessments not always accurate, but also because hospitalists or clinic physicians see many of Marren's patients, there can be a significant gap between discharge from the hospital and the first follow-up visit in the clinic, she explains. To make sure that the patient is discharged to the proper community care and to bridge the gap before the first visit to the physician, nurse practitioners will visit the patient in the hospital. "The nurse practitioner evaluates the patient for risk factors that might result in re-hospitalization or a visit to the emergency department and identifies information that can be given to the family and the home care nurse to help avoid any decline in the patient's condition," she explains.
Although there is no guaranteed method to predict which patients might decline or be at risk for re-hospitalization, reviews of OASIS data have shown that patients who have been re-hospitalized previously, are taking a large number of medications, and have some type of altered functional status are at greatest risk, says Marren.
To address the risk that improper medication management poses, the nurse practitioner will review medications with the patient to make sure that the medication list is accurate, says Marren. "In our pilot program, we are seeing only patients who we have previously had in our care," she explains. "This enables us to take the last medication list we have to the hospital to compare the information collected by the hospital as well as add the new medications," she says. Because patients may not see a physician for as long as two weeks following discharge, the nurse practitioner can ensure that the medications are properly managed and that medication interactions or mistakes won't cause a decline or a re-hospitalization, she says.
While the nurse practitioner will "follow" the patient's care, he or she does not make the initial home care visit, points out Marren. The nurse practitioner's notes are more detailed and more complete than the typical discharge notes, so the home care nurse has more information with which to begin the assessment, she says. "The home care nurse makes the initial visit and completes the OASIS," she says. "If there are any questions, or the home care nurse notices a decline or change in the patient's condition, the nurse practitioner can be consulted by phone".
Because the nurse practitioner has seen the patient previously, he can help the home care nurse evaluate any changes, says Marren. "Home care nurses appreciate the extra set of eyes and ears as well as other ideas from someone who has a clinical perspective on the patient," she says. If necessary, the nurse practitioner will visit the patient at home, she explains.
During the pilot program the nurse practitioner is working with two teams that have an average daily census of 600 patients, says Marren. Of these patients, the nurse practitioner has seen about 120, or 20%, of these patients, she adds. "On average, the nurse practitioner makes one to two visits per day, then spends time communicating with physicians and home care nurses," she explains.
"We're fortunate that we have an integrated documentation system in the hospital that serves the area in which we're running this pilot program," says Marren. The integration means that the nurse practitioner's notes about the patient will be seen not only by the home care nurse, but also by the clinic physician who sees the patient for the follow-up visit.
NPs act as consultants for palliative care
Palliative care specialists often are found in hospice settings but the staff at Home Nursing Agency in Altoona, PA, discovered the need for palliative care consulting for physicians with chronically ill patients in the hospital.
"Hospitalists can call our palliative care consultants to work with families to help them make some of the difficult decisions or prepare to make them in the near future," says Kim Kranz, RN, MS, vice president of operations for the agency. Although the patients are chronically ill, they may not be at the point where they need hospice care, so Kranz does not use hospice employees for this position.
"We asked physicians who would be most likely to use the service what type of person they would be most likely to consult," explains Kranz. "They all agreed that they did not want a physician," she says. Because of the complexities of assessing a chronically ill patient and determining the best place for care as well as understanding the wide range of options for palliative care, Kranz decided to hire nurse practitioners or physician's assistants for the service.
The palliative care consultants visit with the patients and their families before discharge to assess their situation and help the family identify goals for moving their family member to the right agency for care, explains Kranz. Community resources that are available to help families are also discussed, she adds.
In addition to working with the family, the palliative care consultant advises the physician, says Kranz. Because the consultant focuses on palliative care, he or she is aware of different symptom control options of which a physician may not be aware, she adds.
In addition to strengthening the relationship between hospitalists and her agency, Kranz points out that this service is a real benefit to patients and their families. "We make sure that the patient receives the right care at the right time and we offer options that help the patient and family manage their quality of life."
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