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An Innovative Continuum of Care Takes Nurses Back to Their Roots

Summary

Nurses in the Tucson area are not only serving persons in hospitals but also caring for them in their homes and neighborhoods and teaching them how to maintain their health. Three nursing programs—community nursing centers, home health services, and nurse case management—are part of the nursing continuum of care within Carondelet Health Care.

Promoting clients' optimal wellness level, helping them maintain their highest level of functioning, preserving their dignity and independence, and enhancing their self-care are the goals of the Carondelet Community Nursing Centers. Nurse practitioners monitor clients' blood pressure and cholesterol and blood sugar levels and can test for episodic problems.

Carondelet Home Health nurses teach clients about disease processes, symptom management, and medications; assess or monitor a patient's condition; care for wounds, and coordinate services such as physical therapy, occupational therapy, and home-delivered meals. Persons are usually referred to home health as they are discharged from the hospital.

In addition to helping clients with psychosocial problems, nurse case managers perform traditional nursing functions like monitoring and teaching about medications. Nurse case management clients include the frail elderly or persons who have at least one of the following: a chronic disease that is causing steadily declining health; a terminal illness; an acute episode that requires monitoring and support; care-giver stress; or an inability to cope, as evidenced by anxiety, depression or substance abuse. Services for such clients will gain prominence in a reformed healthcare system.

Nurses should be prepared to care for the sick at home as well as in hospital and to serve all kinds and classes of people, rich and poor, the mentally disabled, and families and communities as well as individuals. The teaching of health maintenance and the prevention of sickness [is] to be an important part of their work.

—"The Nightingale Concept of Nursing," in Isabel M. Stewart and Anne L. Austin, A History of Nursing from Ancient to Modern Times: A World View, ed. 5, G. P. Putnam's Sons, New York City, 1962, p. 109

Florence Nightingale changed the care-giving profession a century ago by introducing these revolutionary concepts in nursing. Today one of nursing's contributions to healthcare reform is a return to the profession's roots–not only serving persons in hospitals but also caring for them in their homes and neighborhoods and teaching them how to maintain their health.

Nurses in the Tucson area began the return to those roots a decade ago, thanks to the efforts of members of Carondelet Health Care. Three nursing programs–community nursing centers (sponsored by St. Mary's Hospital), home health services, and nurse case management (sponsored by St. Joseph's Hospital of Tucson and St. Mary's)–are part of the nursing continuum of care within Carondelet's network.

Nursing Centers
The Program Promoting clients' optimal wellness level, helping them maintain their highest level of functioning, preserving their dignity and independence, and enhancing their self-care are the goals of the 15 Carondelet Community Nursing Centers in Tucson, Green Valley, and Nogales neighborhoods, according to the program's coordinator, Evelyn Chapman, RN. "We work with each client to put together a plan to improve his or her health," she said in an interview.

The first nursing center opened after the manager of an apartment building where elderly Hispanics lived expressed his concern for their health to Phyllis Ethridge, St. Mary's vice president of patient care services. He believed the frail elderly in his building needed follow-up monitoring and care after they were discharged from the hospital.

Today these neighborhood-based nursing centers are located in areas with high concentrations of older adults. The centers are housed in apartment complexes, mobile home parks, churches, a low-income housing project, and a physician's office. Each space is borrowed for three hours a week or every other week, explained Chapman.

Usually two nurse practitioners and as many as six volunteers (who greet clients, get charts, and fill out laboratory slips) work at each nursing center, according to Geriatric Nurse Practitioner Amy Ginn. They see 30 to 45 clients during the three hours the centers are open each week. Appointments are on a walk-in basis. Most days the nurse practitioners work at two centers, one in the morning, one in the afternoon. Ginn sees the centers as places where people can socialize, as well as have their health monitored.

St. Mary's is the primary source of funding for the nursing centers. Chapman pointed out that by sponsoring neighborhood nursing centers, St. Mary's promotion of wellness will save money in the long run because the centers will identify clients' health problems early on, helping them keep out of the hospital or use fewer hospital resources. Chapman added that the centers fulfill part of Carondelet's mission "to respond to the health needs of the local community . . . to embrace the whole person in a spirit of healing and loving service."

On May 20 the newest community nursing center opened in Nogales. Chapman noted that right now St. Mary's is assessing where it might need to locate additional nursing centers for a community nursing organization demonstration project sponsored by the Health Care Financing Administration (see "Community Nursing Demonstration Project Will Involve Patients in Their Care," Health Progress, December 1992, pp. 58-59). "We never stop appraising where we are and where we need to go," she added.

Responsibilities In addition to performing standard services such as monitoring clients' blood pressure and cholesterol and blood sugar levels, the nursing center nurse practitioners also evaluate episodic problems such as urinary tract infections, according to Ginn. "We try to keep clients' chronic illnesses from escalating by providing health promotion as we assess health behaviors," added Chapman.

The nurse practitioners can detect even slight changes in the condition of clients who come every week. This regular contact often prevents hospitalization because it enables nurse practitioners to refer clients to their physicians when appropriate, explained Ginn.

She added that seeing a client every week builds a rapport between client and nurse and enables the client to learn self-monitoring techniques. "Even though I may spend only five or ten minutes with one person, it's advantageous for the client and for me as a nurse to detect early problems."

Ginn noted that nurse practitioners emphasize three things at the nursing centers:

• Prevention–urging clients to have routine tests such as Pap tests and pelvic examinations (which can be provided at some centers) and referring clients to facilities where they can obtain tests such as mammograms and prostate screenings at a low cost.
• Monitoring–checking vital signs such as blood pressure, lungs, pulse, and blood sugar.
• Education–conducting classes and one-on-one training. Ginn noted that one-on-one training works best because the nurse practitioner can, for example, teach clients how to improve their diets based on their current eating habits and what they can afford.

Clients Carondelet St. Mary's nursing centers serve all adults, regardless of income, according to Chapman. No fee is charged because this outreach program helps keep clients healthy and active and use fewer hospital resources.

The nursing centers facilitate access to healthcare, according to Chapman. Persons learn about the community nursing centers through word of mouth.

Although the nursing centers focus on the elderly, any adult may come in to be checked. St. Mary's is exploring the possibility of a nursing center for children that would provide immunizations. "We're really lucky in Tucson because other agencies have started teen nursing programs and prenatal nursing programs," added Ginn.

Although Ginn believes nursing is important throughout a person's life, she pointed out that the elderly in particular need nursing centers because they often get lost in the system. "The wellness program can answer questions they may have," said Ginn. "We also need to make them aware that they are at greater risk for certain diseases."

Home Health
The Program Carondelet Home Health, launched eight years ago, is a subsidiary of Carondelet Health Care, according to home health nurse Lydia Kostenbader. Nine full-time and several part-time nurses staff the group practice.

Each home health nurse sees about six clients a day, with a weekly minimum set at 27, explained Kostenbader in an interview. A nurse's total census fluctuates between 20 and 25 at one time. Certain clients, such as those who require wound care, may be seen once or twice a day. Other clients are usually seen two or three times a week for a few weeks, then one or two times a week as they stabilize.

"We set up very specific goals at the outset of care, and when those goals are met, we discharge the patient. The care plan is a real functioning tool; it's not an afterthought the way a lot of medical paperwork becomes," noted Kostenbader.

"Home health is about patient autonomy," she asserted. "We make clients aware of what's going on in terms of their health and give them the information and the tools they need to more successfully manage their healthcare."

Responsibilities Home health nurses visit clients in their homes and at adult care homes–boarding homes for elderly persons. According to Kostenbader, the main duties of a home health nurse include:

• Teaching about disease processes, symptom management, and medications
• Assessing or monitoring a patient's condition
• Caring for wounds
• Coordinating the services a patient needs such as physical therapy, occupational therapy, and home-delivered meals

Kostenbader speculated that without home health, rehospitalization rates would be higher, and the persons reentering the hospital would be more ill. "Routinely, home health nurses are able to catch something early on, call the doctor, and get something handled over the telephone with a change in medication," noted Kostenbader. "Without the help of home health, many of my clients would end up in the emergency room."

Clients Persons are usually referred to home health as they are discharged from the hospital at the request of the physician or liaison nurses at St. Mary's and St. Joseph's hospitals. Some referrals are made from physician's offices, with no hospitalization having taken place. Sometimes Carondelet Home Health gets calls from families seeking help.

Carondelet Home Health sees mostly Medicare patients and has contracts with health maintenance organizations (HMOs), according to Kostenbader. Carondelet Home Health also accepts patients from the Arizona Health Care Cost Containment System (AHCCCS), the state's Medicaid program.

Typical home health clients are persons who need wound care, have newly diagnosed or unstable diabetes, or have unstable lung or heart disease, noted Kostenbader. Home health clients have more acute problems than nurse case management clients, whose conditions are typically chronic, she added.

Case Management
The Program The nurse case management program began at St. Mary's after the implementation of diagnosis-related groups. Patients were being discharged from the hospital earlier, with a higher rate of rehospitalization, said Joan Stempel, professional nurse case manager, in an interview. Each hospital–St. Mary's and St. Joseph's–employs seven nurse case managers. Some are part time.

The goal of nurse case management is to get the client to recognize changes and to call his or her physician when changes occur. "The optimal outcome is to get the client to learn to recognize these things on his own and know what he needs to do about it and follow through," said Stempel.

Nurse case managers see three or four clients each day. Visits normally last about an hour, but vary from 30 minutes to three hours depending on the client's needs. The frequency of the visits also varies, said Stempel. If a client is in a crisis, Stempel visits frequently to provide the necessary help, such as emotional support to a dying person and her family as she decides to get hospice care. Stempel visits stabilized clients who are unable to manage their own healthcare once a month "just to check in, see what's happening with them, keep the relationship going so that if they get into trouble, they will call."

Carondelet Health Care provides nurse case management to people on Medicare who meet the criteria for the services and use the Carondelet system. The cost of nurse case management is included in two HMO capitated contracts for members using these insurers. In addition, with AHCCCS, case management can be provided on a fee-per-visit basis.

Responsibilities When nurse case managers begin working with them, clients are usually not stable physically, and the nurses' focus is on the traditional nursing functions like monitoring and teaching about medications. The ultimate goal, however, is for clients to become as self-sufficient as possible. "We emphasize building empowerment and independence," noted Stempel.

Once a client has become more physically stable, nurse case managers perform some of the nontraditional nursing duties, what Stempel refers to as "cheerleading." "A lot of my clients don't have families close by. They don't feel that anyone really cares whether they take their medications or not. So having someone like me who will touch base with them, even if it's just once a month, gives them a lot of motivation," she added.

Once stable, Stempel explained, clients have the energy to look at factors such as family stressors that are triggering their illness cycles. She described one client who cared for a demanding husband. The only way for her to get respite was to become hospitalized. Once respite care was provided, the client's illness cycle stopped. "We work with the whole family, not just with that one person. It's not unusual for me to provide care for someone who has come into the hospital suffering from an illness created by care-giver stress and then follow the patient home. Then the person he or she is caring for becomes the client" (see "Nurse Case Management: Clients' Perspective" below).

Some clients need someone to listen to their fears–fear of dying, fear of ending up in a nursing home, fear of becoming dependent on their families. "I like the idea of being able to address some of their psychosocial and spiritual issues, as well as the physical ones," Stempel said. "The blend of doing the traditional nursing roles–the monitoring, the teaching, and the emotional support and listening–helps clients learn how to cope. Growing old isn't for sissies; it takes a lot of adjustments."

Clients The nurse case management program is open to anyone who uses the Carondelet system, persons on Medicare, and persons from specific HMOs. The program also serves a small number of indigent patients.

Nurse case management clients include the frail elderly or persons who have at least one of the following:

• A chronic disease that is causing steadily declining health
• A terminal illness
• An acute episode that requires monitoring and support
• Care-giver stress
• An inability to cope, as evidenced by anxiety, depression, or substance abuse

One nurse manages high-risk maternal-child cases. Through a research grant from the National Multiple Sclerosis Society, Carondelet has for several years offered nurse case management care to persons with progressive multiple sclerosis, noted Stempel.

The nurse case management program has two categories of enrollment: active and inactive. Active enrollees are those currently receiving services. Inactive enrollees received services in the past; however, they can reactivate any time they need help or are hospitalized.

Clients are usually referred to nurse case management during hospital stays. Nurse case managers screen clients during discharge rounds. In some cases a family member asks the hospital for help. Referrals also come from social workers, emergency room staff, and physicians.

Continuum of Care
Carondelet Health Care has created a medical continuum of care in Tucson, with patients not only moving through the nursing programs but also being referred to physicians and other healthcare professionals when appropriate.

Nursing Continuum Most clients move through the continuum through home health and case management because they usually have chronic illnesses that include acute episodes. However, some clients stabilize to a point where they can be monitored at the nursing centers.

"If someone needs to be seen more than once a week, we try to get them into home health," said Stempel. Some clients receive both home healthcare and nurse case management, especially if they are having physical and psychosocial problems.

Home healthcare is provided for a shorter period than nurse case management and requires more frequent skilled nursing-oriented care. If a client is seeing both a home health nurse and a nurse case manager, the home health nurse provides the skilled care. The nurse case manager ensures that care is flowing smoothly and sometimes coordinates other services, said Kostenbader.

Once clients have met their healthcare goals, home health nurses may on occasion refer them to the nursing centers; however, most home health clients see their physicians for monitoring. Home health clients who are not mobile are often referred to case management, explained Kostenbader.

If a client can remain physically stable (e.g., is recovering after an acute episode like a heart attack), the nurse case manager may recommend the client visit a nursing center if access is not a problem, said Stempel. Similarly, nurse practitioners in the nursing centers may ask for case management assessments for clients who are too ill to access the centers. "We can slide people back and forth," noted Stempel.

Ginn said that nurse practitioners at the nursing centers will refer clients to case management if their health declines, their chronic illnesses increase, they have been recently hospitalized, they have a mental health problem that the nurse practitioner cannot deal with, or home safety is in question.

Medical Continuum Although nurses throughout the continuum interact with clients' physicians if an urgent need arises, they try to promote independence and the skills for self-care in their clients. Ginn noted that if nurses always contacted physicians, clients would become more dependent.

Nurse case managers do check in with clients who have been hospitalized or entered nursing homes, said Stempel. In most instances the nurse case managers also touch base with the facility's social worker for discharge planning. "A lot of times we have valuable information on the family situation, their coping ability, and their resources," she explained.

Nurse case managers interact with other healthcare professionals when they can provide information that will help, said Stempel. For example, the nurse case manager will tell a client's physical therapist that he or she needs to maneuver a staircase to leave home.

Nursing's Place in a Reformed System
Because the Clinton administration's reform proposal promotes patient autonomy and wellness, community nursing centers, home health services, and nurse case management will be increasingly important.

Ginn believes nursing centers will have a prominent place in a reformed healthcare system because they provide routine monitoring and help patients get early treatment.

Kostenbader believes home health will be central to a reformed system and predicts more people will be referred to home health. "Recovery, healing, and learning about care are often best done at home," she said, adding that the goal of managed care is to keep people well and out of the hospital. She also hopes the reformed system will cover the costs of nursing assistants to provide services such as preparing meals and helping a client bathe.

The need for nurse case managers will grow, not only because of reform but because the elderly population is growing and living longer, said Stempel.

She warned that when there is a new system, people, particularly older people, are going to need help learning how to work it. "Simple things can throw people. Nurse case managers will need to be available to help people through the transition."

Controlling Costs Carondelet's nursing continuum of care controls costs–a goal of healthcare reform–by monitoring clients' health and by teaching them to stay well and out of the hospital or nursing home.

Kostenbader sees evidence that home healthcare also controls costs by keeping people out of the hospital. In addition, she said that Medicare certifies home healthcare for nine weeks, but because clients do better at home, most are discharged earlier.

Nurse case management clients are usually afflicted with debilitating chronic illnesses that lead to many costly hospitalizations. But Stempel said the coordinated care they receive helps them access the system more appropriately. Clients are not coming to the emergency department with health problems that can be handled in the physician's office. Also, a person with chronic obstructive pulmonary disease who develops pneumonia will, for example, enter the hospital sooner, avoiding serious complications and the possibility of being admitted to the intensive care unit on a ventilator.

Without case management, Stempel speculated that her clients would die sooner, be placed in nursing homes more frequently, be admitted to the hospital more often, and use the emergency room more frequently.

"I have had so many clients say, 'My case manager cared about me so much that I began caring about myself.' When that happens, clients start taking care of themselves–taking their medications, eating right, exercising, doing what they are supposed to be doing. That translates into saving money," asserted Stempel.

Mental Healthcare Nurses from the nursing centers, home health, and nurse case management agree that the reformed healthcare system needs to provide mental healthcare.

"Depression runs rampant through the elderly population," said Ginn. Sometimes people come to the nursing centers just to talk, she noted. She described a man who had come to a nursing center three years ago very depressed. Today, he is doing well and is active.

Kostenbader said she believes home-based mental healthcare is needed because many homebound elderly persons are depressed. "There's very little in the Medicare system or the HMOs to pay for mental health services. There's a lot of grief in the elderly, a lot of losses," added Stempel.

The Renaissance
Carondelet's nursing continuum of care has put into practice Florence Nightingale's century-old concept of nursing. Stempel sees it as what nursing was originally intended to be. "We got caught for a long time in the high tech and forgot about the whole person. At Carondelet, we are going back to the beginning. I just wonder if healthcare in general isn't moving in that direction."

—Michelle Hey

Pio Decimo Nursing Center

Residents of Barrio Santa Rosa, one of Tucson's oldest neighborhoods, were suspicious when a free healthcare center opened in 1987, said Amy Ginn, Carondelet geriatric nurse practitioner. But because of the staff's cheerful and relaxed manner, word quickly spread that the center was a good thing. Now, every Thursday morning residents are already waiting when Ginn arrives to open the Pio Decimo Nursing Center.

Pio Decimo, a former convent, was originally converted to a child day-care center. But over time, through United Way funding and private funding, it has become a neighborhood center as well. In addition to day care, Pio Decimo offers senior programs and an on-site housing program for people who are trying to get back on their feet. "It's really a complete program, and the nursing center is just one tiny piece of it," said Ginn.

Many clients come to Pio Decimo each week for assessment and evaluation of their health problems such as high blood sugar and blood pressure levels. Some are visiting relatives in the neighborhood and use Pio Decimo for healthcare monitoring because their physicians are in Mexico.

If Pio Decimo Nursing Center was not available to the Hispanic, low- or fixed-income residents of Barrio Santa Rosa, Ginn believes they would either receive no care or be forced to go to clinics that charge a fee. "I think some of the people we see would get lost in the system," asserted Ginn.

Nurse Case Management: Clients' Perspective

Every two weeks Dorothy and Edwin Jacobson receive a visit from the person who shares their ups and downs, the person who soothes their anxieties about their health–Joan Stempel, Carondelet professional nurse case manager. "When Joan breezes in, she's like a breath of fresh air," said Dorothy from her Tucson apartment.

The Jacobsons were referred to nurse case management in 1992 when Dorothy was hospitalized at St. Joseph's after a niacin overdose caused her to faint. During her stay, Dorothy told hospital staff that she was caring for Edwin, who is blind and has multiple health problems, including high blood pressure, diabetes, and arthritis.

Edwin, who is 82 years old, was an orthopedic surgeon in New York City until the pain of the arthritis kept him from his job. He instead saw patients in his office, made house calls, and worked as a consultant. He retired at age 69.

Dorothy and Edwin moved to Tucson in 1980 to be near their son, who now lives in Hollywood. Their daughter lives in Milwaukee, and other relatives live on the East Coast. So when their health is in question or their anxiety is high, the Jacobsons turn to Joan.

Edwin said he feels safe knowing Joan will be there to check on his health every two weeks in case something comes up between appointments with his doctor. Joan advises Edwin when he should ask the doctor to do special tests and when to see him before his scheduled appointment.

At each visit Joan checks Edwin's blood pressure, blood sugar level, heart and lungs, and feet for circulation problems. In addition, they talk about how diet can help his diverticulitis. "Joan keeps me mentally well," asserted Edwin. "She keeps me going. She checks me out, she answers my questions, she keeps me sane."

Joan advises Dorothy on Edwin's diet, which has to be low in salt, sugar, and fat. She has taught Dorothy what to look for on labels of prepared foods. When Joan first started managing Edwin's care, he was taking oral insulin. Today, Edwin's blood sugar is controlled with diet. Also, intestinal polyps have not recurred since Edwin's diet changed.

At Joan's suggestion, the Jacobsons have begun going out for lunch once a month because Edwin's blood pressure and diabetes are under control. Dorothy noted that these outings are a morale booster for her and her husband. Previously, the only time Edwin left home was for a physician's appointment or a hospital stay. And now that Edwin's health is stable, Dorothy said she feels freer to play bridge with friends every now and then.

Edwin tries not to stay in bed all day. He knows every step of the house–how many steps it takes to get to the bathroom, how many to the kitchen. He walks 500 to 1,000 steps each day. He listens to talking books for the blind. Some days Dorothy helps him out to the balcony where he can sit facing the mountains. "Even though he can't see the mountains, at least he knows they're there," said Dorothy.

The Jacobsons have been married for 45 years. Although the couple has been accustomed to folk dancing and playing tennis, Edwin's health problems have not tarnished their outlook: The Jacobsons remain upbeat.

"It could be worse," said Dorothy, who is 75. Although she does not dwell on it, Dorothy admitted she does worry about what she would do if Edwin became totally physically dependent. Edwin believes Joan is helping him stay well enough to remain at home with Dorothy. "I don't think I'd do well in a nursing home because I wouldn't be able to be with my wife every day."