CASE MANAGEMENT IN THE NICU: IMPROVING SAFE DISCHARGE

Lisa Kohne, RN, MSN, PHN Samuel Merritt University

Is there a need for CM in the NICU?

In 2005, US spent $26.2 billion (national institute of medicine) on neonates. $51,600 per baby

12.7% of babies born in 2005 were premature, 525,000 babies Over 50% of all infant birth charges

Wide variation in LOS, variations in neonatal practice, developing technology.

Average LOS with a complication is 7 days (5 days longer than newborns without complications)

NICU care is one of the top 5 claims costs, with some hitting the million dollar mark and up. Many infants reach life time benefit maximums before leaving

the hospital

What’s going on?

Advances in technology allowing for the saving of very premature infants

Advancing maternal age

Increase in multigestational births

Lack of prenatal care leading to lots of near-term (34-35 weekers)

Common conditions and treatments that lead to

extended LOS

Prematurity

Respiratory distress and ventilation management

near term and VLBW-chronic lung disease

Congenital heart defects and surgeries

NEC (necrotizing enterocolitis)

Futile care for infants who are not viable or have defects that are not compatible with life

ECMO (extracorporeal membrane oxygenation)

Other Conditions

Cardiac/circulatory issues lack of O2 seizures, cerebral palsy, developmental issues

Apnea

Bradycardia

Advanced stage ROP (retinopathy or prematurity)

Feeding intolerance

Family

Patient

Medical team

Specialists Additional

team members

Nursing team; CM

Case Management Model

CM program goals

Improve health outcomes

Decrease costs

CM Program INTERVENTIONS

1. Multidisciplinary Rounds

2. Improved parent teaching and involvement with patient care

3. Safe discharge

Multidisciplinary Rounds

Held weekly for 2 hours. Every member of the patient’s health care team must be present.

Focus on clinical course, patient goals, and discharge

Identify barriers to goals and discharge

CM role

Facilitate meetings

Creating two d/c plans

Health care team members

Nurses CM Bedside RN Charge RN

Medical Team Neonatologists Surgery

Specialists (examples) Genetics PT OT Respiratory Nutrition

Additional members (examples) Social Work Chaplain Pain Palliative care/hospice Developmental psychologist

6 D/C questions for Rounds

1. What is the d/c date? Does it need to change?

2. Is the LOC and setting appropriate?

3. What are the expected post d/c needs?

4. What are the barriers to d/c?

5. Who is accountable for said barriers?

6. What are the next steps for d/c progression? What is the new plan?

Safe Discharge: 7 critical components

1. Sustained pattern of weight gain 2. Physical goals met

1. Suckle feed 2. Maintain normal body temperature

3. Parental involvement and education 1. Participation through clinical course

4. Begin primary care 5. Evaluation of unresolved medical problems 6. Home assessment and home care plan 7. Post d/c tracking and surveillance

1. Parental support

Home Care Plan: 6 common elements

1. Identification and preparation of in-home caregivers

2. Development of a comprehensive list of required equipment and supplies and accessible sources

3. Identification and mobilization of necessary and qualified home care facilities within the home.

4. Assessment of the adequacy of the physical facilities within the home

5. Development of an emergency care and transport plan

6. Assessment of available financial resources to assure capability to finance home care costs

Safe Discharge: 8 Key guidelines for the CM

1. Identify patient caregivers 2. Work closely with patient care givers so as to

decrease surprises and decrease stress 3. Work with Health Care team to develop outcome

criteria 4. Develop a d/c date by day two 5. Attend multidisciplinary rounds

1. Address 6 d/c questions 2. Develop at least two d/c plans

6. Consider Thursday Friday 7. Ensure all follow up care is scheduled 8. Ensure all home health needs have been addressed

Improve parent teaching and increase parent involvement in

patient care

Meet with parents within first 48 hours of admission.

Meet with parents after weekly Multidisciplinary rounds to talk with them about progress and plan and answer any questions or address needs.

Team implementation of Transition Point Teaching

Transition Point teaching

1. By one week after admission 1. Unit orientation - RN 2. Psychosocial assessment - SW 3. Metabolic screening - MD 4. Parent feeding plan identified – MD, RN, & dietitian

2. During level II care and at least 72hrs from d/c 1. CPR training - RN 2. Hearing screening - MD 3. Back to sleep education - RN 4. Bathing & body temperature education - RN 5. PCP identified – MD 6. Car seat education and testing – RN 7. Identification of any special at home needs – MD, RN, & specialist

3. Within 1-3 days before d/c 1. d/c medication education/prescriptions – RN, MD, & pharmacist 2. Follow-up appointments - CM 3. Immunization education – MD & RN 4. Home feeding plan – MD, RN & dietitian 5. Parent satisfactory survey - CM

The Program Goals:

1. Improve health outcomes 2. Decrease costs Interventions: 1. Multidisciplinary Rounds 2. Improved parent teaching and participation in

patient care with the Transition Point Teaching tool 3. Safe discharge Outcomes: 1. Decrease LOS 2. Decrease readmission 3. Decrease parental stress

CM program

.

Pt admitted to NICU CM pt assessment

•Needs •Barriers •Goals

CM care plan developed •Short term goals •Long term goals •Time line – d/c date

Parent involvement

No CM needs identified

Multidisciplinary Rounds •Care/action plan developed

•All team member’s specific goals •6 d/c questions addressed → d/c plans developed

Pt progress

Begin TP teaching

Improved parent teaching and participation

All team members

↓

Safe d/c •↓ LOS •↓readmission •↓stress

7 critical components & 8 guidelines met

+ -

Parent involvement +

↓

↓

↓ 1

2

3

4

5 6 7 8 4 5 6

1 2

3

7

Finish TP teaching ↓

3

3 3

2 3

2

3

2

↓

↓

1.Improved Health outcomes 2.Decreased cost

Evaluation

Process Evaluation Indicators Measurement Goals

Parent education Working with RN staff to

complete patient care.

•Ability to perform care and

verbalize actions

•Completion of Transition Point

Teaching check list

•100% completion of transition

point tool kit

•Decreased readmission for

same diagnosis within one

month

Multidisciplinary Rounds Attendance of entire health

care team associated with

patient care

Roll call/sign in sheet 100% attendance of

Multidisciplinary Rounds by

health care team Outcome Evaluation Indicators Measurement Goals

Length of stay Decreased length of stay in

NICU

Hospital statistics for similar

diagnosis

50% decrease in LOS

Readmission rates Decreased readmission for

same diagnosis to hospital

Patient readmission rates for

same diagnosis over one month

period

50% decrease in readmission

rates

Familial Stress Decreased family stress •Satisfaction and preparation

questionnaires

•Decrease in readmission for

same diagnosis over one month

period

•90% Satisfaction rate and 80%

preparation rate on both

questionnaires

•50% decrease in readmission

rates

Structure Evaluation Indicators Measurement Goal

NICU Nurse case manager NICU education and training Competency test 90% or higher pass rate

Multidisciplinary team •Early evaluation and treatment of patient •Education of parents

•Within 24 hours of patient admission to NICU •Parental involvement in care

•100% •85%

Case Management in the NICU: Improving Safe Discharge

Improve health outcomes and decrease costs through the implementation of multidisciplinary

rounds, increased parental education and involvement in patient care, and safe hospital

discharge. As evidenced by decreased length of stay, decreased parental stress measured via decreased readmission, two parental surveys,

one given at the time of discharge and the other one month later at patient PCP check up, and

decreased hospital readmissions for one month with same diagnosis.

Thank you

?????Questions?????