Three nurses test strategies to improve care and reduce costs
The health care system traditionally has been a bastion of rules, regulations, and rigid schedules. But now a stronger emphasis is being placed on creativity, and nurses are being seen as important innovators who can improve health care while holding down costs.
A case in point: 21 nurses were among the 73 health care professionals selected as “innovation advisors” through the Centers for Medicare and Medicaid Services’ (CMS) Innovation Center in December 2011. As advisors, they have embarked on a year-long effort to test projects that can achieve CMS’ triple aim of better health, better care, and lowered costs though continuous improvement. Successful projects can then be replicated within a health care system and potentially nationwide.
Sharing her expertise from one setting to another
For the past six of her 41 years as a nurse, Maureen Thompson, BSN, RN, CWOCN, has been working as a wound care nurse at St. Francis Hospital, a small, community hospital in Wilmington, DE, that is part of a larger system, Catholic Health East. In her role, she is consulted by physicians and nurses for direction about patients’ wound care, ostomy, and continence needs. Additionally, she educates patients and families and holds inservices for staff on these same clinical issues that can be complicated.
Thompson, a Delaware Nurses Association member, also is always on the lookout for programs that can benefit staff or patients.
Last November, she came across an e-mail message asking health care professionals to send in their ideas to improve care and reduce costs to CMS. If their projects were chosen, they would become CMS innovation advisors and have the opportunity to learn more about health care finance, systems analysis, population health, and operations research; to refine and broaden their projects; and to share their expertise with colleagues. (The facility also receives up to $20,000 to help implement innovative projects.)
“I thought, ‘I can do that,’” said Thompson, who has always been interested in innovation. And she had a project in mind: allowing facilities across the continuum of care to share staff who have certain expertise.
She already knew that such an effort could work. Although Thompson is employed by an acute care facility, she spent four hours a week at a long term care facility, which paid her to provide wound care consults and to educate staff on wound prevention, assessment, and the use of appropriate dressings.
“Within the first three weeks that I was there, we decreased by half the number of wounds occurring in residents,” Thompson said. “The number continued to stay at a low level.” There also were secondary benefits. She discovered that the long term care facility was buying its own supplies, instead of taking advantage of a more cost-effective, system-wide contract that was available to them as part of Catholic Health East. Further, the facility no longer had to bring in a different health care provider at a higher cost.
Since attending the first CMS innovation advisors meeting this January, Thompson’s project — and role — has shifted. Now she divides her time between her regular acute care setting and home health services. In the latter setting, she monitors home health patients’ progress on wound care and, if needed, makes home visits to address complicated or problematic cases. Many of these patients have co-morbidities that can affect wound healing and, in turn, lead to readmissions, according to Thompson. So her expertise, again, allows for improved patient health and reduced overall health care costs.
Since participating in the CMS program, which includes webinars, onsite meetings, and ongoing support, Thompson reported gaining many skills and tools.
“Now I have a better ability to look more broadly at issues, as well as break down a problem of great enormity — see why it happened and how to address it by applying a true process,” Thompson said. She further shares these skills and tools with staff whom she works with, and continues to brainstorm and communicate best practices with her fellow-CMS innovators.
Predicting and preventing hospital readmission
For more than a year, Laura Beth Brown, MSN, RN, president of Vanderbilt Home Care Services, has immersed herself in an effort to determine which patients are likely to be readmitted into the hospital after discharge and what action plan can be implemented during their stay so they don’t quickly return. She believes home care services could play a vital role in preventing these readmissions, which are costly to patients and health care systems. It is Brown’s quest for a predictive model and potential interventions that led CMS to select her for their initial group of innovation advisors.
“Our system was not utilizing home health as much as other [hospital] systems,” said Brown, a past president of the Tennessee Nurses Association. Nationally, about 18 percent of patients are discharged from the hospital with home health care, while 8 percent or less of Vanderbilt patients were going home with this same type of post-discharge care.
And her clinical intuition told her that certain patients — such as someone who has been hospitalized twice in the past six months, is on 20 medications, is living alone, and has a history of falls — could highly benefit from more targeted interventions while transitioning from hospital to home.
Further, national data buttress her observations. For example, for every increase in the number of medications a patient takes, there is a 1 percent increase in re-hospitalizations, Brown said.
“I wanted to create a tool to help providers make decisions in real time based on data that will better predict patient needs,” she said.
In January 2011, Brown began working with an interdisciplinary team comprised of experts in Vanderbilt’s electronic data warehouse (which stores information Vanderbilt collected on its patient population for 10 years), a social worker, physicians, and another nurse to create a predictive model, or tool, for readmission. The model uses 12 variables, such as pressure ulcers, deep vein thrombosis, and risk for falls, to predict whether a newly admitted patient is 40 percent or more likely to be readmitted.
“If you know who’s at risk early enough, there are things we can do before and after they transition from the hospital to their homes,” Brown said. “And because we are using data that we already collect, there is no extra work for staff.”
Now that Brown and the team have a predictive model, they are working to develop a targeted bundle of interventions that can be implemented as part of at-risk patients’ plans of care. Those interventions for a patient with a neurological condition, for example, might include having an interdisciplinary team routinely “huddle” to discuss ongoing concerns; a “time-out” before discharge to determine if all the patient needs, including new issues, have been addressed; and a plan for home health services.
Brown also envisions the model being implemented in other settings, as well as being used to help them predict other factors, such as patient satisfaction.
Brown encourages other nurses to apply for the CMS program. “You’re investing time that will help your own (hospital) system and maybe others,” she said. “It requires you to really think about why you’ve always done things a certain way and what really matters to the patient.”
Improving continuity and care coordination
Becoming involved in the CMS program is a natural extension of Barbara Blakeney’s current role as an innovations specialist at Massachusetts General Hospital in Boston.
Blakeney, MS, RN, FNAP, a member of the Massachusetts Association of Registered Nurses and past president of the American Nurses Association, sees the CMS program as an intriguing opportunity to capture clinicians’ expertise and use “implementation science” to influence practice and patient care.
“Implementation science is a way to get good data that makes sense without having to control for all the variables that can occur with patients and in health care,” according to Blakeney. It also allows clinicians to quickly “adapt, adopt, or abandon” models or workplace strategies being tested.
One of the projects that Blakeney is experimenting with at her facility — and that piqued the CMS Innovation Center’s interest — is a new staffing role called the “attending nurse.”
“The attending nurse concept came from Jeanette Ives Erickson (DNP, RN), our senior vice president and CNO for Patient Services, and it’s part of an ongoing, larger initiative to engage in better practices and interventions to ensure a better process and outcome for our patients,” she said.
One of the main goals of the attending nurse is developing and coordinating the team’s strategic clinical plan for the inpatient admission. The nurse in the attending role works eight hours, five days a week to promote continuity over the patient’s stay, which generally is four to five days.
Attending nurses look for any gaps in care and unmet needs that patients and their families may have from admission to post-discharge. They also may carry a light patient assignment.
Officially launched March 19, the program is being tested on12 units by nurses who volunteered for this role. Patient satisfaction is expected to rise, because direct care nurses will spend more time with their patients and the attending nurse will keep all aspects of their care on track.
Blakeney noted that nurses have been behind many other innovative projects at Massachusetts General. For example, nurses decided to wait to give certain early morning medications until after rounding when they most likely could be changed or discontinued. Now, patients are getting the medications they need when they need them.
“There is no lack of creativity at the bedside,” Blakeney said. “Initiatives like the CMS program help nurses’ creativity blossom into innovations that can be used across systems.”
Established by the Affordable Care Act, the CMS Innovation Center fosters health care transformation by finding new ways to pay for and deliver care that improve care and health while lowering costs.
• For more information on the CMS Innovation Center, go to: www.innovations.cms.gov.
• To learn about the CMS Innovations Advisors Program, go to: www.innovations.cms.gov.
— Susan Trossman is the senior reporter
for The American Nurse.