The ‘Missing Link’ Beyond Our Doors

The UW Health Transitional Care Program provides a very important service to a variety of patients in both the medical and surgical settings. Although each patient has a unique care plan, the goal is steadfast: prevent avoidable readmissions.

One way Laura Sell, MA, BSN, RN and colleague, Dani Edwards, MSN, RN, PCCN – who both serve as transitional care case managers – keep that goal front and center is by continuously looking at all sides of the care provided before, during and after each procedure, to try and find ways to improve it.

“The patients we work with have had a surgical procedure – typically an ileostomy – related to a colorectal disease of some kind,” says Sell. “Many of these patients are at a high risk for readmissions, so we analyze every step involved in their care and think, ‘What would I want if this were me?'”

It is this empathic viewpoint that allows Sell and Edwards to determine if enhancements can be made to the care plan or the way the care team communicates throughout the continuum of the patient’s care, including after they’ve left the hospital.

“There are many dynamics in play with these patients,” continues Sell. “Not only are they dealing with a physical appliance that they need to adjust to and learn about, there are dietary guidelines they need to adhere to. So, understandably, there can be a great deal of anxiety and angst associated with all of it.”

In an attempt to ease this stress, Sell and Edwards look for gaps and themes that help them know exactly where to target their improvement work, and who to work with to get it done. Feedback from patients indicate that they are already impressed with the services provided by the transitional care team.

One particularly rewarding example involved a 69-year-old female patient who came to UW Health’s University Hospital for revision surgery after having been through several surgeries at another hospital.

When Sell met with the patient in the hospital, she talked through the transitional care-surgical brochure with the patient, explained the program and explained that she would be calling her for up to six weeks. The patient was also given Sell’s cell phone number so that she would call her directly with any questions she had.

“The patient took the brochure, raised it up and said, ‘THIS is the missing piece that the other hospital didn’t have.'”

“When I called her at home, she said she had been extremely tired and struggled with eating and drinking,” Sell said.

Upon Sell’s assessment, the patient was indeed dehydrated, as she suspected. She was directed to see her primary care physician that day for further care.

“What you do is so important,” the patient told Sell. “You even care about us after we go home.”

And the patient is exactly right, especially when it comes to Sell’s dedication to improvements. Here are a few of the most notable changes she’s been instrumental in moving forward:

• Creating a practice protocol to ensure consistent management of high output ileostomies across the continuum of care. They collaborated with colleagues at the Digestive Health Center to develop it and presented it to the unit nurses and to the Nursing Practice Council.
  
• Increasing awareness of diet and fluid intake and output among wound and skin, ostomy and home health nurses.
  “The nurses are now noting output, so it’s working,” says Sell. “There was only one patient readmitted in two years for an ill-fitting appliance. Most readmissions have been for dehydration, so this increased awareness is making a difference.”
  
• Surveying patients before, during and after their procedure, to see if they received enough information about their stoma, lifestyle, diet changes and appliance.
  
• Collaborating with pharmacy colleagues to develop opioid-tapering patient instructions.
  
• Working with the UW Carbone Cancer Center nutritionist to facilitate easy referrals via Health Link (electronic health record), for patients struggling with meeting nutrition requirements after surgery.
  
• Reinforcing consistent order sets for all consults on ostomy patients. Sell and Edwards helped make changes to the post-operative order sets so that no matter where a patient is roomed, they’ll have consistent order sets for all consults – nutrition, behavioral health ostomy care service and notify provider for ostomy output <500 in 8 hours or >1200 in 24 hours.

Sell and Edwards maintain their commitment to improvements and have a few new initiatives in progress and on the horizon.

“We recently succeeded in implementing a new process related to home health that’s needed for patients with ostomies over the holidays,” Sell said.

“Typically, home health staffing is low during this time, so if you have a patient that’s leaving during those times, home health care might not be available,” Sell explained. “As a work-around, we suggested that home health get ordered before the patient goes home (pre-surgery). It’s tricky because it’s not our workflow. So, we met with colleagues at the Digestive Health Center (DHC), presented the idea and hammered out the details, which resulted in the resource center finally being available to DHC just like it is to case managers at University Hospital. Home health referrals are now initiated before surgery.”

Sell and Edwards are also considering videos as another patient education option, and a better system for rehydration – outpatient option versus inpatient – among other things.

“Improving processes and patient care is intrinsic to our nursing practices and our program,” Sell says. “Seeing that these changes are making a difference in patients’ lives is beyond rewarding.”