Team spirit between visits

The medical home is all about continuous and coordinated care. One thing that means is maintaining continuity between our typical 15 minute visits. In fact, for people with chronic diseases like diabetes, hypertension, and asthma, this is where most of the care and for that matter, most of the illness resides. We all know that what we do as doctors 2-4 times per year in our 15 minute office visits does not impact these folks with chronic diseases very much. What they are doing, eating, drinking and watching during the time they are not in the office has much more impact than what we do in the office. The question becomes, how can we use our offices, despite being locked in fee-for-service arrangements, to assist our patients with their out-of-office, "life" care?

In our practice, through lessons learned in TransforMed, we have made between-visit care the domain of the nursing staff. This makes sense, since they are not bound by any fee-for-service arrangement; they are paid hourly. We incorporate the nurses in our visits from the very beginning, as important members of the care team. The patients get to know their nurse and hopefully become as comfortable with him or her as they are with their doctor.

At the beginning of each visit, the nurse checks in the patient following a protocol that begins with ascertaining the chief complaint, obtaining vital signs and creating a prioritized list of issues. The nurse then initiates a conversation regarding preventative care and advises the patient which studies are due. If the patient doesn't want to do a test, the nurse notes down the reasons. Next are immunization recommendations, followed by the most important question: "What is the goal of your visit?" We get the most valuable information in the answer to this question. The entire nursing process only takes 2-3 minutes per visit, but it helps build the patient's sense that the nurse is an important member of the care team. It also sets up the patient's expectations nicely to match with that of the physicians. We find that the visits go more smoothly with less disappointment and fewer "Oh, by the way..." moments as the doctor is exiting the room.

Between visits, our nurses return phone calls to answer patient questions, refill medications using a physician-approved protocol and inform patients of their lab and test results. (I'll have more to say about the refill protocol in a later entry.)  They get to know the patients, their family support systems, which home health agency they use, which pharmacies they use, etc. This background information is  valuable in making care personal and efficient. The patients are able to get more individualized care with a team, not just a doctor, taking care of their needs whenever they arise.

The nurses also do recall projects between visits, letting patients know when they are due for visits and other services and helping them schedule appointments into their busy lives. Since the nurses take ownership of this between-visit care, they can really see how the whole picture comes together and have more understanding of how people cope with their illnesses 24 hours a day, 7 days a week. At the same time, the patients come to feel that their care is truly continuous and coordinated, not just episodic and visit based. Everybody ends up with more team spirit.

Posted at 04:31PM Oct 20, 2009 by Melissa Gerdes, M.D.  |  Comments[1]