Are you facing the challenges of repeat ED visits, re-hospitalizations,
soaring costs due to non-compliance and frustrated healthcare teams from
those “non-compliant” patients? Let’s review a case study and some
recommendations that might help us think differently about our
approach.
I remember it like it was just yesterday. I walked into a home, doing a home
visit for an elderly woman. I was working in Palliative Care and Hospice, and we had a referral to help this woman manage her chronic diseases
without daily calls to the clinic, near-weekly visits to the ED recently, and
monthly admissions to the hospital. She was labeled as non-compliant and
a “difficult patient”.
I knocked on the door and heard a loud voice respond, “What do you
want?” I tried to explain that I was a nurse and that her doctor asked me to
visit her. The response was, “Fine, come on in if you think
you have to”.
I walked in and went around the corner to see this elderly woman sitting in
a chair with a table filled with medication bottles, a nebulizer sitting on
another table, a walker next to her chair, and an Oxygen concentrator
placed in the corner. On the other side of the room was a large crafting
table filled with so many crafting supplies and tubs all around the table.
I introduced myself and then was able to focus on the bright pink carpet
and sparkling ceilings. The furniture was all very brightly colored. I knew
right away I had a spicy patient with a strong sense of independence.
The conversation was a little tense at first, but within 20 minutes, she was
able to see I was there to listen and partner with her to improve her quality
of life. After that initial challenging period, her guard came down and I
listened for about 30 minutes to all her challenges. Then
, we could discuss her goals for the rest of her life.
She shared how she used to decorate massively for every holiday.
The visual was incredible.
I’m always amazed at the goals that patients can share once they
know we are there for them.
Her goals were:
1. Go to the park again with her grandchildren
2. Go to Walmart to get more crafting supplies
3. Once again, Be able to work on her crafts.
What was preventing that was the challenges her care regime created for
her and the feeling that no one was listening, just prescribing. She had a
regime where almost every hour she had to either take a medication or do
a treatment. We realized that she had been seeing multiple specialties
and getting add on to her treatment plan, but no one had looked at the
whole care plan from a bird’s eye view to realize that it was impossible to
adhere to this plan and have a life or any rest.
Over the next couple weeks, we partnered with her physicians, NP,
Pharmacy and created a much simpler and effective schedule for her.
Simple things like scheduling meds together when possible, setting up a
med planner, and simplifying her treatment regime made a difference.
We met with her family to review the new plan. They agreed to support this
plan and support her. Her mood improved greatly and she was a true delight to
visit with.
Over the next year, her health improved to a very stable state; she visited
the ED once and was subsequently hospitalized for a few days. We did
visits to brainstorm any challenges she was facing and to verify
compliance. The previous year had been over 20 ED visits and monthly
hospitalizations. This new year, she got to Walmart a few times
to stock up on supplies and had a schedule with friends and volunteers that
helped her organize her supplies and craft with. She went to family
holidays and grandchildren’s concerts. She went to the park with her
grandchildren several times with the help of her son. She became near
100% compliant with her care regime.
She passed a couple of years later, and I went to visit her near the end. She
was so grateful for all we had done to improve her life and give her
precious time with her family and friends and truly enjoy so much time. The
human connection, the ability to hear what the patient wants, the
ability to partner with the patient and various health care professionals to
create a care plan that supports the patient’s health and quality of life.
An additional bonus is the healthcare costs saved, the burden on the
clinics, ED, and hospitalization being dramatically reduced. This was only
one of dozens of case studies with a similar scenario.
So, how can we move forward to create these win-win situations for our
patients, families, and healthcare systems? It is a multipronged approach
including such things as:
Care Coordination: Employ care managers or coordinators to
partner with patients to navigate and provide input into their
care, partner to create treatment plans that work for disease
management and patients’ lives, create tools to support patients
to manage their conditions, integrate remote monitoring when
appropriate, prevent crises, and manage them when a
crisis does occur. This program is recommended to include visits
to the hospital when the patient is there, home visits, and
partnering with other services they have.
Education and Support : Provide resources
and training on managing chronic conditions, helping patients to
understand the disease process, what a great care plan regime
can do, and identifying goals that inspire them to manage their
disease(s) well. If patients understand the what and why behind
what we are suggesting they do, compliance improves.
Patient Empowerment: Identify with the patient what matters
most to them. Then, engage patients in their own care through
goal-setting and self-monitoring tools. Partner with them to
decide on what to monitor and how to manage the prevention and
intervention phase. Engage family or friends when possible so
that they have a social and support structure.
We are here to help you provide coordinated care, partnership, and quality, and
during the process, save millions of dollars in healthcare utilization costs
and expenses to your system.
Reach out today to schedule a call so we can explore your current
challenges and if a similar program might also solve your issues.
www.firstqualityconsulting.com
meg@firstqualityconsulting.com