Bobbie Gordon, left, and Kim Harrell are nurse care managers with the BJC ACO.
Remember when you were young and your parents made sure you ate right, saw the doctor regularly and took your medicine when you should?
That same type of care and concern is shown to patients by a special group of nurses who keep in touch with their patients by phone. Have they kept their doctor’s appointment? Taken their medicine? Are they eating balanced meals and taking proper care of themselves?
Medicare patients of BJC Medical Group doctors have that service as a part of BJC Accountable Care Organization (ACO). Nurse care managers call patients when they are discharged from the hospital, or when they have been identified as being at a high risk of hospital admission due to chronic disease.
Many of the group of seven nurse care managers and a social worker are housed in doctors’ practices. They keep the physician updated through the patient’s electronic medical record.
“Sometimes patients find it hard to reach their physician, or hesitate to call when they have questions,” says Bobbie Gordon, RN, BSN, MBA, a care manager in the ACO. “Because we are nurses, they feel comfortable calling to say ‘Is this something I should be concerned about?’ or ‘Is there something I should do?’”
Patients receive one to four phone calls, depending on their situation. Some patients, though, can continue to receive calls for months if needed.
Answering Questions Can Mean Fewer ED Visits
Sandra had been a frequent user of emergency services for symptoms she believed were urinary infections. Gordon contacted her following one of these ED visits and developed a rapport with the patient.
“I gave her my contact information and she began calling me with questions rather than just going to the ED,” Gordon says. “We found out her symptoms were from a variety of causes, including medication side effects.”
Sandra is now seeing her primary care physician regularly and being treated for chronic back pain. She has also given up smoking, and the medication side effects are better controlled with a few changes. She has not been back to the emergency department since last July.
The nurses often find the high cost of medications have prevented patients from filling their prescriptions.
They then talk with the prescribing doctor to see if there is a less expensive alternative, and if not, find out if financial assistance can be arranged. At other times patients are confused by their hospital discharge instructions, or once home they may decide that they need home care or home medical equipment.
“Navigating through the health care system can be challenging,” says Megan Guinn, RN, BSN, manager of care coordination. “Our goal is to serve as a resource during a time when a patient’s health care may be intense or confusing. We hope to empower patients by providing them the information and tools they need to be successful in managing their own health.”
Gordon says many patients become good friends along the way. “My patients can call me during off hours, whenever they need. I am their cheering squad and problem solver. As nurses we can help educate them, troubleshoot illnesses and direct patients to the proper care.
“I am always commenting on how cute the patient is that I am working with. My coworkers tell me I say all my patients are cute!”
From Ice Cream to Independence
Kathleen, 57, was a frequent user of Christian Hospital’s emergency room, always arriving by ambulance. She was a smoker with swallowing issues and breathing problems, and was unable to leave her home for very long. Kim Harrell, RN, BSN, began working with Kathleen as part of BJC ACO.
Working jointly with the Community Health Access Program (CHAP) at Christian Hospital that uses a paramedic to visit patients in their homes, they identified issues such as trash build-up due to Kathleen’s inability to walk to the dumpster and other medical and psychiatric issues.
Harrell says Kathleen has gone from only eating ice cream to eating healthy meals, has decreased her smoking, has a cleaner home with better air quality and is now able to walk to the drug store to pick up her prescriptions. Her calls to 911 have dropped from five times in a week to no calls over four weeks. She has also not been to the ED since April and is keeping her doctor appointments.
“Every patient has a story,” Harrell says. “Our role is to get on the phone, build a rapport and get them talking. They are usually very grateful just to be heard. We are able to have an impact in the moment.”
In the Words of a Patient
“Just a quick note to thank BJC for implementing the nurse care manager program. After my release from Barnes-Jewish Hospital St. Peters, my nurse was instrumental in aiding me with prescriptions, calling doctors and follow-up calls to the doctors. Without her help, my road to recovery would have been very difficult. Thanks for a wonderful job well done!”