There's No Place Like Homecare

by Carol N. Dunbar, RN, MS, CNS

When Alice Johnson transferred from another home healthcare agency she weighed 77 pounds. She has a fistula that was draining gastric contents onto her skin and required 400 (yes, 400) dressing changes a week. On her first visit, the nurse was in touch with the Visiting Nurse Service of New York Wound and Ostomy Center of Excellence. Together with the wound/ostomy clinical nurse specialist (CNS), who made a home consultation, followed by five telehealth visits, the home care team developed a pouching system for the drainage, and investigated every aspect of the patient's care from lab results to nutrition. They then collaborated with an acute care CNS to find the right surgical team to close the fistula. At last report, Mrs. Johnson's fistula has completely healed, she has gained 33 pounds and is enjoying a new quality of life.

Not content to rest on its national reputation, VNS-NY in 1993, under the direction of Joan Marren, Chief Operating Officer, created The Centers of Excellence, a division of Quality Management Services. The centers were designed to promote best nursing practices in home care with the leadership of the CNS. "I think that Marren demonstrated excellent vision," says Maureen Dailey, RN, MSN, CETN, director, Centers of Excellence and Disease Management. "She recognized that the CNS has the expertise to set up the policies and procedures, the protocols, and to develop patient and nurse education material. She also recognized that the CNSs can bring expertise to the front lines and to the nurses via consultation on complex cases."

The Centers of Excellence

VNS has four Centers of Excellence: Oncology and Pain Management, Cardiopulmonary, Diabetes, and Wound and Ostomies, each staffed by a CNS who specializes in that field. In addition, VNS has CNSs who specialize in HIV/AIDS, maternal child health, asthma, and community mental health. Just as Marren envisioned, the Centers of Excellence provide expert clinical consultation to staff and physicians, set policies and standards, create educational materials, promote clinical expertise, collaborate on research projects, and provide leadership in influencing population management guidelines.

Plan Put to Practice

While this program sounds ideal in theory, does it work in practice? Take the case of Estelle Brown,* a 56-year-old woman who returned home after surgery for a bowel obstruction, not only with a new colostomy, but also with a new diagnosis of bladder cancer. She was overwhelmed and had many questions and concerns. Charlotte McLoughlin, RN, BSN, a new nurse having graduated in 1998, was assigned to the case. When Charlotte met Estelle, she knew she would be consulting with Kay O'Brien, RN, AOCN, CS, the oncology and pain management CNS.

O'Brien receives referrals for pain and/or oncology management, and her first actions are to check the records and referrals, institute a plan of care, and email a consultation to the on-site nurse. Consultation can address the adverse effects of chemotherapy, symptom management, or recommendations for pain management.

"She is an excellent support for us," explains McLoughlin. "O'Brien is approachable and helps us make sure that we are doing everything that we can for the patient." In Estelle Brown's case, that care meant education on what to expect from chemotherapy, the importance of hydration, pain management options, and helping her identify questions to ask her doctor. The nurse taught Mrs. Brown how to schedule her activities around the chemotherapy schedule to allow for rest on the days following treatment.

In addition to her consultations, O'Brien has developed assessment and education tools for nurses. "We have a patient teaching guide," O'Brien says, "a symptom management guide for nurses that specifies information that must be reported to the physicians, and a one page pain clinical practice prompt that is based on the Agency for Healthcare Research and quality (AHRQ) guidelines." It was formerly called the Agency for Health Care Policy and Research.

One-page tools, or prompters, have been developed by the CNSs that contain the essential must-do information for the home care nurse. "They are not a lengthy care plan, but a one-page document that contains the critical elements for out identified needs areas, including congestive heart failure, COPD, diabetes, wounds, and pain assessment," explains Dailey.

Wounds Care CNS Consult

Yurcania Villalona, RN, BSN, coordinator of care at VNS is a true believer in the value of the CNS consultation. "Sometimes there is so much involved in a case," she says. "The CNS can provide the expertise and their experienced point of view. They have the literature; they know what products and resources are available. The CNSs can help you see that maybe, there is something else going on. And they help nurses see a different perspective."

Robert Estes,* a 60-year-old paraplegic, has been treated successfully in the past for stage three sacral decubitus. When the ulcer came back in spite of following the protocols, Villalona consulted with Marianne Bradley, RN, MS, CWOON, the ostomy wound care CNS. "Together, with Marianne, we checked everything," Villalona recalls. "His red blood cell count was low, so Marianne recommended iron supplements for wound healing. We were also able to upgrade his status with Medicare to get him a new therapeutic mattress."

Not satisfied with these interventions, the nurse and CNS explored further and found that Mrs. Estes had been prescribed physical therapy for an injury she had sustained. Though she had independently cared for husband until now, the time she spent in physical therapy meant her husband has to spend longer periods of time in his wheelchair. A home health aid for her husband for three hours a day solved the problem and the wound healed successfully.

Technological Support

"We try at least once to personally see all of the people with ostomies who are referred to us," Bradley says. "We are also able to do consults through telehealth. The nurses can take digital picture of wounds that we view, and then we meet with the nurse to discuss a plan of care," she adds. According to Bradley, her role is to teach the nurses to think critically, to better manage the patient. She encourages them to look holistically at the patient and ask, "What are the causes of that wound?"

Additionally, Bradley teaches an advanced wound management class, acts as a liaison with physicians, and has recently completed a formulary card that lists 90 products available to the nurses for wound and ostomy care. The wound care team holds presentations on different or difficult cases, offering the latest information on treatment and technology. The CNS also uses data collection to follow practice patterns.

Through the Centers of Excellence, each CNS consult is electronically entered into the database. "In wound care, as an example, we track and trend the type of wounds we're seeing, we track and trend practice patterns, then we partner with the leadership team to give them feedback," Dailey adds. "When things are going great we like to give praise, and when there is opportunity for improvement we work with the leadership in the regions to do education and skills labs," she says. Through this program, VNS has been able to significantly reduce pressure ulcer incidence among their 25,000 patients. According to Dailey, pressure ulcers are the most costly home care wound category--not just in dollars--but also in human terms. Through the Centers of Excellence they are able to reach more nurses, provide more education, and better examine their practice patterns.

As with her CNS colleagues, O'Brien fulfills each of the professional roles of the CNS, consultant, researcher, educator, collaborator, and mentor. Though the roles are varied, Bradley does admit, "Mentoring is my favorite thing to do. I enjoy working with the nurses, teaching them what I do, helping them ask the important questions, and eventually grooming them to take classification exams. My role is to pass on to the nurses what I know, and what I've learned." Lillian Wald, our founder, would be proud.

* Names have been changed.

From Nursing Spectrum - New York/New Jersey Metro Edition. Copyright June 4, 2001. All rights reserved. Used with permission. http://www.nursingspectrum.com