Seamless care for respiratory patients

Staff reaches out to patients following Emergency Department visits

TUESDAY, OCTOBER 4, 2011 :: By Jennifer Gladwell

GOT QUESTIONS? GET ANSWERS
Use this contact information to find out more.

Management co-lead(s)

Helene Ingletrhon, RN manager, Helene.M.Ingletrhon@kp.org

Union co-lead(s)

Meg Tannehill, RN, labor co-lead, UFCW Local 7, Meg.Tannehill@kp.org

Members of the Chronic Care Coordination unit-based team

Highlighted Tools

• High-Performing Teams [Informational Page]

Once patients leave the hospital, many feel lost and confused about what they need to do to stay well. The Chronic Care Coordination unit-based team in Colorado recognized this gap and now contacts every patient with chronic obstructive pulmonary disease (COPD) who has been seen in the Emergency Department (ED) for respiratory issues. 

Using improvement tools such as plan, do, study, act and a decision matrix, the team put a process in place that helps patients care for themselves after they’ve gone home. They created a COPD assessment and plan of care with goals for each patient and made it standard practice. Patients say they appreciate the follow-up. 

“We had an opportunity to listen to the patient,” explains Beverly Kruse, RN, team co-lead. 

Better coordination for prevention 

The team also found opportunities to work with primary care departments for follow-up. For example, when nurses make follow-up calls to patients, they are able to set up appointments with their primary care providers on the spot. Nurses also check on such other patient issues as financial concerns, health education gaps, their ability to manage their disease at home and opportunities for outside resources—like smoking cessation programs. 

The team members’ efforts have won them recognition. Team members presented their project at the KP Quality Conference in June, and they also won the Colorado UBT Value Compass award. See the video here [KP Intranet].

The transformational journey 

The Chronic Care Coordination team wasn’t always the high-performing group that it is today. As one of the first teams in the Colorado region, UBT members didn’t have a blueprint for success or the benefit of other teams’ experience and successful practices. Initially, team members were not invested in working as a unit-based team. They struggled with decision making, geographical issues and how to apply LMP principles to their work. 

Working in the team was like “trying to herd cats,” says Helene Inglethron, nurse manager and co-lead. “We had input but couldn’t make a decision.” 

The team members agreed to restructure the UBT into a representative model. Team members re-wrote their charter and repeated their training in the Rapid Improvement Model (RIM). They now meet regularly and are applying the tools they have obtained. 

“This project changed the UBT to the working body it is today,” says co-lead Kruse. 

What’s next 

The team plans to expand its program to all COPD patients—not just those presenting with respiratory issues—who go to the emergency department. It hopes to expand the program to other vulnerable patient populations.

“The objective is to offer interventions before a member's condition progresses,” says UBT member Meg Tannehill, RN, member of UFCW Local 7.  “It's the classic Kaiser philosophy of prevention of events versus the more traditional mode of reaction after events.”