How many doctors do you have? A primary care physician, perhaps a specialist or two? It turns out that the average Medicare beneficiary has seven unique physicians.1 That’s a lot of people to keep in the loop.
It can be tough to manage and coordinate care while also keeping everyone informed, but of the many responsibilities that care management entails, one of the most important is just that: communication. Effective care management and communication can be the difference between a patient being able to stay healthy at home or ending up back in the hospital.
Read on to find out how Liza, a Residential nurse, prevented a patient from being readmitted to the hospital by facilitating successful communication between multiple parties: a patient, a caregiver, a hospital and a home medical equipment supplier.
The patient, “Sally,” was admitted to home care due to a recent hospitalization for pneumonia, an onset of atrial fibrillation (a-fib), and new in-home oxygen. Sally also has chronic obstructive pulmonary disorder (COPD) and chronic heart failure (CHF). Sally had just started on oxygen due to low oxygen saturations with minimal exertion. She was sent home from the hospital at 4:30 p.m. with a 4-hour oxygen tank and instructions that more oxygen would be delivered that evening.
Residential Nurse Liza’s Story:
Around 8:30 p.m. the night that Sally was discharged from the hospital (right around the time more oxygen was set to arrive), I received a phone call from her asking where the oxygen was. Not good - it had not yet been delivered and Sally needs her oxygen to stay healthy. Residential Home Health does not distribute oxygen, so I explained this to Sally. But knowing that the oxygen was vital to her health, “not my problem” was not an acceptable endpoint. Instead, I advised Sally and her husband to hold tight and that I would get to the bottom of the problem.
I called the hospital and spoke with the discharge nurse. She assured me that the order was sent to a home medical equipment supplier and gave me the name of the supplier.
I followed up with the home medical equipment supplier and was informed that they had not received any orders.
From here, I called my patient Sally and her husband to fill them in - and also to let them know that I would follow up with the hospital to obtain the information needed to get the oxygen ordered. Before ending my call with Sally, I verified that the oxygen tank was still half full – it was important to keep track of how much time she had before the oxygen needed to be delivered.
I called the hospital back to let the discharge nurse know that the oxygen order had not been received. I then requested that she ask the on-call hospitalist to sign the orders so that Sally would be able to stay home with her own oxygen and avoid going to the emergency room overnight to get oxygen there.
After several more calls back and forth between the home medical equipment supplier and the hospital, I was able to get the orders faxed and the oxygen ordered. I called Sally and her husband with the good news and they were very thankful to be able to stay home and not add more stress to an already stressful situation.
I then received a call stating the oxygen was at the patient’s home for delivery…but no one answering the door and the line was busy. I tried calling the patient myself and also was unable to get through. I then contacted Sally’s daughter who in turn gave me an alternative number for Sally. I was able to reach Sally and let her know that the oxygen was being delivered and that the technician needed to be let in. Thankfully, she got her oxygen and stayed safely at home with her family.
Communication can be messy and complicated, but it can be done successfully. Liza was able to keep Sally from being rehospitalized due to a mistake in orders by being persistent and dedicated to resolving the issue. The patient was able to stay home and receive the necessary oxygen, making a huge impact on safety and quality of care. Having a provider on your team who takes responsibility and brings your whole health team together can be invaluable.