Transcript Guided Care for Vulnerable Older Patients

Guided Care:
The Nurse’s Role in a New Model of
Care for Older Patients with Chronic
Conditions
Kathleen Grieve, RN, BSN, MHA, CCM
Guided Care Nurse
Johns Hopkins HealthCare LLC
Programa ITERA. II Curso de formación
Hospital del Mar
Barcelona, Spain
20 y 21 de marzo de 2009
The Guided Care Model
Specially trained RNs based in primary
physicians’ offices
GCNs collaborate with physicians in
caring for 50-60 high-risk older
patients with chronic conditions and
complex health care needs
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Sr. Juan Lopez *
76 years old
Retired teacher, lives alone
2 daughters, live >15 miles
away, have jobs and
families
Wife of 55 years, lives 5
miles away
5 chronic conditions
6 physicians
14 medications
*Sr. Lopez is a fictional patient
based on case histories of several
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Sr. Lopez has been referred to a
Guided Care Nurse for enrollment
in the program.
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Enrollment
1. Call patient to schedule home visit for initial
assessment
2. Review medical record and record data
3. Home visit (1-2 hours) with patient alone or
with caregiver
4. Enter all data into Electronic Health Record
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Enrollment cont’d
5. Print Preliminary Care Guide and review
6. Meet with Primary Care Provider
7. Create and print Care Guide
8. Create and print Action Plan
9. Visit patient again to review and seek approval
for Action Plan
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Assessment
• Perform initial assessment (history, reconcile
meds, social issues, patient goals, etc.)
• Use standardized assessment tools
– Nutrition Screening Initiative checklist
– Mini-Mental State Examination
– Get Up & Go test
– Geriatric Depression Scale
– CAGE
• Screening questions
– Hearing impairment
– Falls
– Urinary incontinence
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Sr. Lopez
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Heart Failure since 1991
COPD since 2001
Hypertension
Renal disease
H/O abdominal aortic aneurysm, glaucoma
Ischemic cardiomyopathy w multiple MI’s –
implanted cardioverter-defibrillator
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Sr. Lopez cont’d
• 3 hospitalizations for HF exacerbation or
dehydration in 12 months prior to
enrollment
• Adherence issues re: weight monitoring,
diet, and O2 use
• Family alienation/patient’s anger and
impatience
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Ongoing Guided Care
• Using motivational interviewing techniques
GCN elicited agreement from patient to
contact her to report daily weights
• Patient also agreed to begin walking 20
min/day at least 5 days/week.
• Following PCP dictated protocol, GCN
verifies that patient is taking appropriate
Lasix dose.
• Monthly coaching & monitoring calls
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Guided Care Nurses’ Activities
Assess needs and preferences
Create an evidence-based “care guide”
Monitor patients proactively
Support chronic disease self management
Educate and support caregivers
Communicate with providers in EDs, hospitals, specialty
clinics, rehab facilities, home care agencies, hospice
programs, and social service agencies in the
community
Smooth transitions between sites of care
Facilitate access to community services
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How Has Sr. Lopez Been Doing?
• Last hospitalization was 2 months after
enrollment (10/2006)
• “Temper tantrums” are handled with an
understanding of his behavior – he is
“allowed” to have them
• Family meetings have eliminated problem
of patient “telling different stories”
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Allocation of GCNs’ Work Week
Assessing new pts, caregivers
Monitoring and coaching
Smoothing transitions
Addressing emerging issues
Communicating with PCPs, other providers
Accessing community resources
Facilitating caregiver support groups
Documenting activities
Travel, meetings, email, practice staff
TOTAL
Hours
3.5
8
4
4
3
0.5
1
8
8
40
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Key Word Is “Relationship”
• With patient
• With family/caregiver
• With physicians
Time builds trust.
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Comments from Guided Care
Nurses
“I am practicing
nursing the way
it was originally
envisioned –
holistic patient
care.”
“I enjoy the patients and
the direct access to the
physician and ‘worker
bees.’ It is great to be in
the PCP’s practice,
working side by side – a
true partnership.”
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Comments from Guided Care
Patients
“Guided Care
is like having
a nurse in the
family.”
“Now we can cut
through the phone
system and get to
our physician
through you.”
“Thank you for all your help. Since you have
been working with me, I’ve been feeling better.
Also, I’m using that list that you gave me to help
me know what to look for to take care of myself.
I’m glad you are there for me.”
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Comments from Primary Care
Physicians
“Guided Care
gives you eyes
and ears outside
the office.”
“What a wonderful,
collaborative boon
to patient care!”
“I developed a
closer relationship
with my patients
through the Guided
Care Nurse.”
“Because of the Guided
Care Nurse’s coordination,
I was better able to care for
my patients.”
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Supported by:
The John A. Hartford Foundation
The Agency for Healthcare Research and Quality
(AHRQ)
The National Institute on Aging (NIA)
The Jacob and Valeria Langeloth Foundation
Kaiser Permanente Mid-Atlantic States
Johns Hopkins HealthCare LLC
The Roger C. Lipitz Center for Integrated Health
Care.
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www.GuidedCare.org
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Kathleen Grieve RN, BSN, MHA, CCM
[email protected]
[email protected]
All Guided Care forms are protected by copyright. Anyone who
wishes to use them for their own personal purposes should buy
the book ("Guided Care: A New Nurse-Physician Partnership in
Chronic Care") from www.Amazon.com or directly from Springer
Publishing (www.springerpub.com/guidedcare). No one is
permitted to make multiple copies.
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