At a time when service counts more than ever, the Atlanta VAMC
established a formal customer service program to better meet the
needs of our veterans, their families, and employees. This program
focuses on providing prompt, informative, and courteous service
to all of our customers. Two specific aspects focus on ambulatory
care patients: our Customer Welcoming Station and the Service
Representative Program. Both significantly improve patient and
employee satisfaction.
In the past, patients had few ways to obtain assistance during
their visits to our outpatient area. Although the Patient Representative
was available to provide this assistance, having only one individual
serving as an advocate was not sufficient and did not meet our
standards of exceptional customer service. Our goal is to have
all 2,000 medical center employees serve as advocates each day.
To accomplish this, we developed the Service Representative Program
to involve large numbers of our employees in customer service
functions.
This program was designed to have each service provide at least
one individual to work with our Customer Service Office in assisting
patients and providing five-star service. Individuals selected
as Service Representatives serve a one-year term and provide special
assistance to customers in areas related to their expertise. Employees
participate voluntarily and receive special customer service training
throughout the year from outside educators, as well as guidance
from the Patient Representative. Their functions include addressing
patient complaints, family concerns, employee requests, and working
on customer service programs for the medical center. For example,
if a patient comes to the hospital with a concern related to his
medications, we now have an experienced, well trained, and identifiable
employee in the Pharmacy dedicated to completely delighting the
customer.
As our Customer Service Program evolved further, we developed
a Customer Welcoming Center located in the main waiting area of
Ambulatory Care. This center is staffed by two GS-6 Patient Representative
Associates and one volunteer from 7:30 a.m. to 5:00 p.m., Monday
through Friday. Immediately upon entering the outpatient area,
patients are now greeted by staff who ask them, "How may
we help you?" Here, patients may receive directional assistance;
schedule appointments; ask questions about eligibility, travel,
and other benefits; or be personally escorted to their destination.
The staff work closely with the Patient Representative and the
Service Representatives to ensure prompt and professional attention
to questions and concerns presented by customers. Outpatients
have grown so accustomed to finding immediate, friendly assistance
at the Welcoming Station that it is almost always their first
stop when they come for their visit.
Benefits
Since implementing these programs, the number of patient complaints
has decreased by more than 33% from the previous year. Also, the
amount of positive mail we have received about the medical center
has doubled. Therefore, we spend less time answering congressional
inquiries and more time with our customers.
We have also enhanced our ability to manage front-line workers
and have been able to institute a new work philosophy for these
individuals. Our employees are now expected to delight the customer,
and they understand why it is so important to do this. As these
customer service initiatives continue to grow, we also have begun
to receive more requests by employees to become participants.
Thus, we continue to expand the base of individuals who want to
extend themselves for our customers.
Contact Person: Chuck Bedo, MHA
Service: Office of the Director
Facility: Atlanta, GA VAMC
Number: (404) 728-7724 or FTS (700) 248-7483
Staff members identified the need to have a person in the Triage
waiting area who could provide information to family members of
patients being seen in Triage. It was felt that this position
would coordinate efforts to get information to family members,
reduce complaints of excessive waiting, reduce visitors in the
Emergency Room, and generally provide better customer service.
In light of a recent FTEE reduction, we decided to use a light
duty employee to provide this service.
The duties assigned are:
Benefits
This service has been met with tremendous support and gratitude
from patients and staff. It has reduced complaints from family
members in this area and has provided better coordination of information
for waiting family members.
Contact Person: Vivieca Wright
Service: Ambulatory Care Service
Facility: Nashville, TN VAMC
Number: (615) 321-6361 or FTS (700) 850-4751
F or the past three years, Big Spring VAMC has operated Haven
House, a resi- dence that provides lodging and food for wives
and female relatives and friends of hospitalized veterans. Billed
as "a place of honor for wives of hospital veterans,"
the residence opened 3-1/2 blocks from the medical center in November
1991. It is open to women friends and family members over the
age of 16 for as long as they need to stay. They may contribute
a suggested $3.00 or $4.00 per night if they wish or may stay
with no charge; free food is always available in a well stocked
pantry. The typical stay is for two or three days; two women stayed
for more than 60 days. Usually three to six women are there on
a given night, but there has been as many as 13 women guests on
the same night.
Haven House was originally donated by a VA employee, Lona Hood,
who saw the need for such a facility while she worked at the VA.
It is not officially owned by the VA, but by a non-profit corporation.
Social Work serves as the Inn Master, dispensing keys and registering
guests; the Social Work Service secretary serves as Chief Inn-keeper.
The home is supported by private donations from various service organizations; considerable rivalry has developed among groups wishing to be associated as donors. Unsolicited donations easily surpass the average monthly operating expenses of less than $300 per month. Donations have come from as far away as Alaska, and veterans groups in Tyler and Amarillo, Texas, some 200 and 400 miles away, have been regular donors.
Benefits
Haven House is a gesture by VA staff to honor veterans' families
and let everyone know, whether or not they use the home, that
VA cares in a special way for veterans. The women who stay there
write frequent letters of praise; many talk of the friendships,
fellowship, and therapy they derive from other women staying at
the home. It has been a positive experience for veterans, families,
service organizations, and VA staff, and it has brought much praise
for the medical center.
Contact Person: John Webb, LMSW
Service: Social Work Service
Facility: Big Spring, TX VAMC
Number: (915) 264-4850 or FTS (700) 728-7040
T he Iowa City VAMC is undergoing reorganization and moving toward
patient- centered care. In May 1994, Surgical Service made a registered
nurse responsible for managing and implementing a patient focused
environment in the Orthopedic Section. A few of the resulting
innovations are:
Benefits
The pre-operative screening telephone calls have decreased the
percentage of Operating Room cases that are canceled. By having
a specific registered nurse responsible for managing the Orthopedic
Section, patients know who to contact when they have questions
or problems. The change has enhanced patient satisfaction, improved
communications and efficiency, and provided Orthopedics with a
more patient-centered focus.
Contact Person: Dr. Kimberly S. Ephgrave
Service: Surgical Service
Facility: Iowa City, IA VAMC
Number: (319) 338-0581 or FTS (700) 863-6011
In an attempt to ensure patients receive the care they need and
reduce no-show rates, we introduced an Automated Patient Reminder
System (MUMPS Audio Fax) in February 1995. This system, which
interacts with DHCP, calls veterans with a recorded reminder of
their pending clinic appointments. An additional feature allows
veterans with a touch tone phone to cancel appointments when called.
The system improves the efficiency of clinic scheduling by increasing
the number of patients who keep their appointments and making
canceled appointment slots available for other veterans. If a
veteran does not wish to be reminded of his or her appointment,
the number can easily be "flagged" so that the computer
bypasses it. The scripted message also reminds patients to present
any insurance information to the clinic clerk. This has helped
in updating our computer data base and should increase our future
MCCR revenues.
The overall system cost was approximately $80,000 including supporting
PCs, hardware and 12 phone lines. Implementation requires IRM
assistance. However, the system is written in MUMPS and is fully
compatible with DHCP, making the installation no more difficult
than any other DHCP upgrade or change.
Benefits
Many veterans have commented to Ambulatory Care personnel that
the reminder call they received was helpful and much appreciated.
No-show rates have dropped significantly.
Contact Person: Larry P. Meschkat
Service: Medical Administration Service
Facility: San Antonio, TX VAMC
Number: (210) 617-5137 or FTS (700) 779-5137
At the Oklahoma City VAMC, we instituted a pilot program to loan
beepers to family members of patients in both ambulatory and inpatient
surgery. Our goal was to provide emotional support for our customers.
The 14 beepers we used had been turned in by staff as newer models
became available. A clinical staff member decided whether loan
of a beeper was appropriate and together with the family member
determined the loan period. The beeper was provided by Police
and Security personnel, who instructed the family member in its
use. During the nine month pilot, the beepers were loaned about
200 times with an average loan period of about a week. None were
lost or stolen.
Based on the success of the pilot, we extended the program into
the MICU, CCU, and Telemetry, using funds from service organizations
to purchase five new beepers. Our long-range plan is to continue
to expand the program until beepers are available for family members
in all areas of our facility.
Benefits
A survey of staff involved in the pilot program indicated that
all of them believed our goal of providing emotional support had
been reached. In a survey of family members, 100% of the respondents
described themselves as "satisfied" to "highly
satisfied" with the program. Family members wrote narratives
describing how much safer they felt having a beeper because they
knew staff could reach them if they left the waiting area. Other
benefits are decreased noise due to a reduced need for overhead
paging, increased staff awareness of their obligation to notify
family members of changes in the patient's condition or location,
and less crowded waiting areas.
Contact Persons: Kristi Morehead, M.Ed. and Dorothea Hunt, RN
Service: Psychology Service
Facility: Oklahoma City, OK VAMC
Number: (405) 270-5168 or FTS (700) 742-3140
Results from the Customer Feedback Survey in 1994 indicated that
a significant number of veterans at the Atlanta VAMC felt that
they and their families had not had adequate communication with
staff about their illness and treatment. Since the survey had
focused on veterans who had been discharged from inpatient status,
the discharge process was evaluated by medical center QI task
forces. They decided that we needed an immediate follow-up contact
with each of our discharged patients, and Social Work Service
seemed the logical service to "bridge" the discharge
process.
In May 1995, social workers began making phone calls to every
patient who had been discharged from the medical center on the
preceding day or over the week-end. The only exceptions are patients
who were transferred to another facility and those discharged
from substance abuse treatment. There are an average of 22 discharged
patients called each day by two social workers, each of whom devotes
a half-day to this task.
The objectives of the telephone calls are:
During the phone conversation, the social worker inquires about
specific aspects of the discharge experience, such as the receipt
of discharge instructions, medications, and appointments, and
invites the veteran or his caretaker to talk about his overall
treatment experience and his initial adjustment to home. Then,
the veteran is asked to rate the hospitalization and to make suggestions
for improving the care we provide. Arrangements are made to supply
any missing discharge items and to answer any treatment questions
by linking him to the appropriate resource at the medical center,
such as our Telephone Advice Program. Results of the conversation
are recorded and sent to the QA office and to the Chief of Staff
for forwarding to the appropriate service.
Benefits
The response of both patients and social workers has been positive.
Veterans express gratitude for being contacted, candidly talk
about their experiences, and are pleased to offer suggestions.
The phone calls seem to have a neutralizing effect on those who
were not satisfied with their care and provide an opportunity
for veterans who had a good experience to express pride in the
VA. Addressing problems immediately upon discharge decreases the
anxiety and frustration of patients and their families, freeing
them to concentrate on recuperation. Also, patients are more likely
to use hospital telephone services, if they have already experienced
a therapeutic phone call and are sure who to contact. Social worker
morale has improved because they feel their efforts benefit both
the individual patients and the overall operation of the medical
center.
Contact Person: Sherry Murphy, LCSW
Service: Social Work Service
Facility: Atlanta, GA VAMC
Number: (404) 321-6111 Ext. 6350 or FTS (700) 248-6350
Our substance abuse detoxification program was converted from
inpatient to outpatient during fiscal year 1995. The inpatient
detoxification program had averaged over 2,000 admissions per
year for many years, with the average length of stay ranging from
four to seven days. After careful analysis, it was determined
that only a small percentage of these patients required acute
medical detoxification. We also observed that many patients who
were being admitted to our 28 day inpatient rehabilitation programs
could appropriately receive outpatient rehabilitation treatment.
The inpatient detoxification program in Psychiatry Service was
closed. The staff from that program were used to establish an
outpatient detoxification program, reassigned to support a smaller
inpatient detoxification unit on Medical Service, or used to provide
additional support to our outpatient substance abuse clinic. Due
to the decreased staffing needs of the outpatient programs, the
medical center was able to recoup approximately eight FTEE.
Approximately 50 patients per month complete the outpatient detoxification
program, while about 20 require inpatient detoxification. Outpatients
who are homeless or lack a supportive environment are provided
shelter through a VA contract with a local, state licensed substance
abuse facility. This arrangement provides them with a safe, structured,
and supportive environment while going through outpatient detoxification.
With the additional outpatient staffing, we are able to offer
a larger number and a wider variety of outpatient rehabilitation
groups. The patient to staff ratio in these groups has been cut
from a 25-30 to 1 ratio to a more therapeutic 10-15 to 1 ratio.
Benefits
Cost savings for the first year of care are projected to be $600,000
with no negative impact on patient care. Patients have received
dispositions that are more appropriate for their needs, while
ambulatory substance abuse services have been enhanced. Staff
morale has also improved because patients are screened more carefully;
the result is a more motivated patient who is sincerely interested
in his or her rehabilitation.
Contact Person: John Rader, HSO
Service: Psychiatry Service
Facility: Little Rock, AR VAMC
Number: (501) 370-6629 or FTS (700) 740-1340
U ntil recently, substance abuse rehabilitation was done in a
traditional 21 day inpatient rehabilitation program at the West
Los Angeles VAMC. Because of the large number of veterans with
substance abuse disorders seeking treatment, waiting lists for
treatment extended beyond four weeks. We also felt that many of
our patients were becoming institutionalized by frequent and lengthy
hospitalizations, and we wanted to break this cycle.
In April 1995, our inpatient services were redesigned to focus
on acute detoxification, stabilization, and engagement in substance
abuse rehabilitation. The number of beds was decreased, and staff
were redeployed to an Intensive Outpatient Treatment of Addictions
(IOTA) Day Hospital. This program provides rehabilitation services
for alcoholism and addictions five days per week, serving as an
alternative to and a step down from acute hospitalization for
patients who are able to commute. Admission criteria are consistent
with the patient placement criteria of the American Society of
Addiction Medicine.
Day hospital care typically lasts four weeks but can be extended
up to eight weeks, and is followed by maintenance treatment in
our Substance Abuse Outpatient Clinic or in community programs.
Patients attend the day hospital for six hours per day. Services
include evaluation and treatment planning; dual diagnosis treatment;
psychoeducation; group, individual, and family psychotherapy;
training in relapse prevention; urine and breath toxicological
monitoring; vocational rehabilitation; social skills training;
and required community 12-step meetings. Homeless patients are
assisted in locating housing in community sober living homes.
Community shelters are used for temporary housing, and the medical
center domiciliary is used for stays up to three weeks to address
concurrent medical problems. To facilitate attendance, patients
are given bus tokens.
Benefits
IOTA's intensive outpatient treatment allows the least restrictive, most cost-effective treatment of addictive disorders. The lower costs associated with ambulatory treatment permit a longer duration of intensive rehabilitation. In addition, the waiting period for substance abuse treatment has been reduced from one month to within 24 hours.
IOTA's intensive treatment promotes patient bonding, while access
to the world outside allows practice of learned behavior and assists
with mastering skills to prevent relapse. The program provides
gradual integration into community self-help programs and other
resources and is able to operate in conjunction with non-institutional
housing. Most importantly, by providing an alternative to inpatient
hospitalization and emphasizing community re-integration, transition
through IOTA avoids institutionalization of patients in the VA
treatment system.
Contact Person: Mace Beckson, MD
Service: Psychiatry Service
Facility: West Los Angeles, CA VAMC
Number: (310) 268-3904 or FTS (700) 748-3904
I n response to excessive inpatient lengths of stay for patients
with suspected lung cancer, in 1993 the Philadelphia VAMC initiated
a program to perform lung cancer workups entirely on an outpatient
basis. One room in the pulmonary suite was converted to a patient
exam area for use as a "Nodule Clinic," and the Pre-Bed
Care Unit was engaged to provide nursing care for patients undergoing
outpatient bronchoscopy or needle biopsy. The pulmonary fellow
and attending "on service" for a given month were assigned
to staff the new clinic. An RN was designated to assist patients
with scheduling of multiple outpatient appointments for pulmonary
function tests, exercise tests, CT scans, and nuclear medicine
scans. Multidisciplinary conferences with radiologists, radiation
therapists, medical oncologists and thoracic surgeons are extensively
used for review of individual cases. The pulmonary clerk-typist
assists with scheduling and record retrieval. In short, a complete
program for outpatient care was established to move lengthy inpatient
workups entirely to the ambulatory setting. When the work-up (including
diagnosis and clinical staging) is complete, the patient is expeditiously
referred to thoracic surgery, radiation therapy, or medical oncology
for treatment and follow-up.
Benefits
Patients are able to live at home and complete complex testing
with less disruption of their lives, and pulmonary fellows and
attendings develop expertise in providing outpatient care. The
VA has benefited greatly in terms of diminished costs and less
need for inpatient care. For example, in April 1995, six of 15
new cases of suspected lung cancer were handled as outpatients.
Given an average length of stay for lung cancer of 10.5 days,
we saved 63 inpatient days in a single month.
Contact Person: Mitchell Margolis, MD
Service: Pulmonary (Medical Service)
Facility: Philadelphia, PA VAMC
Number: (215) 823-6428 or FTS (700) 481-6428
T wo perceived needs at the Denver VAMC were to improve continuity
of patient care around the time of a patient's hospitalization
and to broaden the training of Internal Medicine (IM) residents
in the ambulatory care setting. We initiated an Office Based Medical
Team (OBMT) service that replaces one month of inpatient ward
experience for IM residents and focuses on patients with subacute
on medical conditions who may require hospitalization. Patients
seen by the OBMT are referred from the ER or other clinics, or
are recently discharged inpatients. Their acuity of illness is
nearly severe enough to require inpatient care, but close outpatient
follow-up may prevent hospitalization.
Three to four house staff are supervised by an attending physician,
usually from the Ambulatory Care/General Medicine Division. The
day begins with a one-hour Ambulatory Morning Report focusing
on recent cases and related literature. The remainder of the day
is spent seeing patients scheduled into the OBMT clinic, consulting
on ER patients, and following short-stay admissions to the OBMT
inpatient service. Residents contribute to decisions regarding
whether a patient should be closely followed in the outpatient
setting or admitted to the short stay unit with likely OBMT outpatient
follow-up.
Benefits
The primary benefit of the OBMT service is improved continuity
of care for patients with subacute illnesses. During the first
six months, a mean of 226 scheduled clinic visits per month were
made, and an average of 30 additional patients per month were
seen from the ER. Approximately five to nine hospital admissions
were prevented each month due to the close follow-up that was
available in the outpatient setting. Patients with a wide variety
of diagnoses, including atypical chest pain, congestive heart
failure, and constipation, were cared for on the short-stay inpatient
unit, avoiding potentially more protracted admissions to the traditional
medical service.
The rotation was also very popular with house staff receiving
a mean score of 5.6 on a 1-7 scale (7=best rotation ever, 11/18
residents responding). Sixty-four percent of the residents noted
that this rotation reinforced their desire to work in General
IM/Primary Care or stimulated interest in primary care not previously
noted.
Contact Persons: Daniel G. Richie, MD and Thomas J. Meyer, MD
Service: Ambulatory Care Service
Facility: Denver, CO VAMC
Number: (303) 393-2839 or FTS (700) 322-2839
T o reduce health care costs, our hospital has attempted to identify
diagnostic procedures that could safely be performed in an outpatient
environment. The most recent initiative (January 1995) is the
Cardiac Observation Unit (COU) in which outpatients safely undergo
invasive cardiac procedures, including diagnostic catheterizations
and electrophysiology studies.
COU staff prepare patients for the procedure, perform the test,
and recover the patient afterwards. They also educate patients
and their families about the test, the findings, and the plan
of action. Patients arrive at the hospital the day prior to the
procedure for laboratory tests, an EKG, and a physical exam. They
stay at a local hotel overnight at the VA's expense if they live
more than 50 miles from the medical center, at home if less than
50 miles. The next day they arrive at the hospital at 8 a.m. and
have the procedure. The COU nurses monitor them during recovery
and provide discharge teaching. The patients and their families
then may either return to the hotel or home.
Fifty to 60% of diagnostic catheterizations are performed on an
outpatient basis. The appropriateness of an outpatient procedure
is determined collaboratively by nursing and cardiology staff,
using the following criteria:
Benefits
From January 1995 through October 1995, 202 outpatient catheterizations
were performed and 555 inpatient days saved. Patient satisfaction
has been monitored since the program's inception; the data have
been very positive. Patient and family comments indicate appreciation
of the additional education provided by the COU, the relaxed atmosphere
allowing for family involvement and discussion with staff, and
the freedom from hospital admission.
Contact Person: Kendra Szymanski, RN, BSN and Mark Starling, M.D.
Service: Nursing and Cardiology Services
Facility: Ann Arbor, MI VAMC
Number: FTS (700) 374-7978 or (700) 374-7976
I n September 1992, our medical center realized that it would
soon become necessary to restrict acute care beds to those patients
who needed them. A survey was initiated by the Chief of Surgery
to determine the placement of surgical patients who required minimal
care and observation for less than three days. The results showed
that 30% of patients meeting these criteria were occupying acute
care beds. A task force was created to make recommendations regarding
the treatment of these patients; it identified over 40 diagnoses
whose pre- and post-procedure treatment required minimal nursing
care and observation if the patient's baseline functioning involved
self-care.
The Nurse Administered Outpatient Unit (NAOU), an outpatient unit
to keep patients overnight without admitting them as inpatients,
was established on a vacant ward located on the ground floor of
the hospital. The ACOS/Ambulatory Care has overall program responsibility,
and Nursing Service administers the unit. As many as 17 self-care
patients may be on the NAOU at any time. Nursing FTEE is 6.0 RNs;
one RN covers the night shift. A CNA from the Mobile Resource
Team assists with vital signs during the busiest shifts which
are Monday through Thursday.
Patients are scheduled for beds beforehand, with nursing staff
screening each patient's appropriateness for the NAOU. Same-day
patients are given beds when they are available. A self-medication
program has been instituted, and arrangements with Nutrition and
Food Service enable patients to ambulate to the dining room or
receive a meal at the bedside when necessary. Patients ambulate
to their diagnostic appointments or are taken in wheelchairs by
Escort Service. The NAOU staff is authorized to make a referral
to or request a consultation from any hospital service.
Physicians utilize the unit for over 95% of appropriate patients.
They appreciate the greatly reduced paperwork requirements: no
discharge summaries are required and only brief H & Ps related
to the patient's procedure. There is also a reduction in the documentation
requirements for nursing staff.
Benefits
The unit costs less than $250 per patient day in comparison to
over $600 on a medical or surgical ward. Between 150-210 patients
are cared for on the NAOU each month, with an average length of
stay of less than 48 hours. Because acute care beds are now at
a premium, as predicted three years ago, Tucson VAMC is in a much
better position to care for the increasing numbers of veterans
migrating to the Southwest.
Surgery cancellations related to patient non-compliance or transportation
problems have decreased, and patients are more knowledgeable about
their procedures and after-care. The NAOU has become a "point
of reference" for those who have been treated there: They
regularly return to greet the staff or to have new questions answered.
Contact Person: C. Kay Morris, RN
Service: Nursing Service
Facility: Tucson, AZ VAMC
Number: (520) 629-1898 or FTS (700) 765-6011
U pon review of Joint Commission standards, it became apparent
that variation in the care provided to patients recovering from
conscious sedation existed within our facility. In the Medical
Endoscopy Clinic, patients were provided privacy, appropriate
monitoring of vital signs, and pulse oximetry by professional
staff during the acute recovery phase. In other areas, such as
Surgical Endoscopy and Pulmonary Bronchoscopy, patients recovered
on an inpatient nursing unit. These patients were being hospitalized
for procedures which could have been performed in an ambulatory
care setting if pre-procedure and post-procedure care was available.
Recognizing the need for change, several key staff proposed a
conversion of an under-utilized area of the facility at a cost
of approximately $14,000.00. Located near Pulmonary Medicine and
the Bronchoscopy Suite, the area provided ample space for a self-contained
unit which included Surgical Endoscopy and a Conscious Sedation
Recovery Unit (CSRU) complete with a negative flow isolation room,
a family waiting area, and a patient changing room. The CSRU is
manned by ACLS certified, fee base RNs, who have successfully
completed a Post-Procedure Recovery competency review in our Post-Anesthesia
Care Unit. Guidelines for care, discharge criteria, and documentation
forms are currently being standardized throughout the facility.
Benefits
From the outset, the care provided in the Conscious Sedation Recovery
Unit met or exceeded accepted clinical practice guidelines and
Joint Commission standards. Within two months of becoming fully
operational, the shift from inpatient to outpatient care was dramatic.
Approximately 25% of both endoscopies and bronchoscopies were
performed on an outpatient basis, reducing the cost to the facility
by approximately $600-$1,200 per procedure. Since the workload
fluctuates daily, staffing the CSRU with fee base nurses has proved
to be efficient and economical. Patient satisfaction and patient
safety have significantly improved, although it is too soon for
data to be reported.
Contact Person: Beverley A. Freeman, CNS
Service: Nursing Service
Facility: San Antonio, TX VAMC
Number: (210) 617-5196 or FTS (700) 617-5196
A need for better coordination of outpatient diagnostic work-ups
for both Medical Service and Surgical Service patients was identified.
In our affiliated medical center, many resource utilization decisions
are made by resident physicians who rotate in and out of the medical
center each month. These residents are often frustrated by the
administrative processes required to care for their patients.
As a result, patients who need complex pre-procedure workups are
often admitted to the hospital, because the resident views admission
as more efficient than facing the challenge of coordinating outpatient
work-ups.
The goal of the Coordinated Outpatient Testing Center (COTC) is
to reduce procedure length of stay by shifting as many diagnostic
workups as possible from inpatient to outpatient care. Two nurses
(one coordinator and one patient-educator) were transferred to
Surgical Service; with one MAS support staff, they began a pilot
program coordinating work-ups for General Surgery and Cardiology
patients. Once the pilot is complete, clinical sections will be
added progressively until all appropriate patients are coordinated
by the COTC.
Working closely with physicians staff and residents, the coordinator
is responsible for the administrative duties involved in the work-up.
A "COTC Day" is determined once a procedure date is
set, and the COTC coordinator schedules all diagnostic tests for
this day, including complex tests such as stress tests and pulmonary
work-ups, as well as standard EKGs, laboratory tests, and chest
x-rays. The diagnostic results are collected by the coordinator,
and abnormal results are brought to the attention of the treating
physician. Pre-procedure patient education and an anesthesia consultation
are also performed on the patient's "COTC Day."
Benefits
Because the COTC is still being piloted, it is too early to report
on the benefits. Data on the following indices are being collected
and will be compared to historical data: number of patients served,
proportion who are same-day admissions, proportion who are ambulatory
surgery patients, number of patients whose surgery procedure date
lags beyond the thirty day laboratory expiration, reasons for
ambulatory surgery cancellations or postponements, surgical cancellation
rate, and pre-operative length of stay.
Contact Person: Bruce Wyllie, AO
Service: Surgical Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 or FTS (700) 383-1740
T he lack of coordination among services to provide timely pre-operative
medical evaluation for patients resulted in an average pre-operative
length of stay of 5.1 days and a surgery cancellation rate of
21% in 1992. The underlying causes of this problem were studied
by UCLA Health Services graduate students, directed by Quality
Management staff and assisted by Anesthesia, Surgery, and Nursing
Services. Data came from interviews of patients and hospital staff,
DHCP files, operating room records, and medical records.
Based on the initial findings, we initiated a pilot project which
involved:
Benefits
The pilot of the new ambulatory pre-operative system began in
July 1994 and was completed in November 1994. At the end of the
pilot period, the pre-operative length of stay for Pre-op Clinic
patients decreased from 5.1 days to 1.1 days, the surgery cancellation
rate dropped from 21% to 12%, and the ambulatory surgery workload
increased 12-fold, from 30 cases per year to 30 cases per month.
The annual savings generated by reducing pre-operative and post-operative
lengths of stay may be substantial.
Contact Person: Dean Norman, MD
Service: Chief of Staff
Facility: West Los Angeles, CA VAMC
Number: (310) 824-3136 or FTS (700) 748-3136
Until recently, ambulatory surgery patients at our facility were
admitted, pre- pared, and discharged by nursing staff on a busy
inpatient surgical unit. Since this assignment was rotated among
staff on a daily basis, several problems emerged:
At a brainstorming session, it was decided that the Nurse Manager
of the OR would oversee the operation of the Ambulatory Surgical
Care Unit and that one RN position would be transferred to the
OR for ambulatory surgery. The new RN position has the following
responsibilities:
Benefits
The surgical schedule is completed in a more timely manner since the ownership of delays is simple to establish, and the overtime budget is used only for emergency procedures as it is no longer needed for delayed procedures. On the follow-up calls,
100% of the patients have indicated they would return to this
facility for another surgical procedure. The reorganization has
also resulted in improved communication between surgeons and nursing
staff. Problems are now discussed at the monthly surgical staff
meeting and resolutions are made by the multidisciplinary team.
Contact Person: Lois Ann Atkins, RN
Service: Nursing Service
Facility: Erie, PA VAMC
Number: (814) 868-6212 or FTS (700) 726-6180
An overnight lodging program was instituted to decrease hospital
admissions. This program allows patients to stay overnight in
a local hotel at VA expense before a scheduled procedure or appointment
and thus stay out of the hospital until it is time for their appointment
or procedure. Family members often stay with them at the hotel.
Certain criteria apply: veterans awaiting therapeutic or diagnostic
procedures must live more than 50 miles from Ann Arbor, and veterans
awaiting outpatient appointments in a clinic not available at
a closer VA facility must reside more than 200 miles away. Once
eligibility is determined, admitting staff set up reservations,
transportation, and, if necessary, meals.
During FY 94, ambulatory surgery accounted for 50% of the patients
who were lodged by the program. Patients with outpatient appointments
were another 29%, radiation therapy patients 16%, chemotherapy
patients 3%, and cochlear implant patients were 2%.
Benefits
The financial benefits of the program are significant. On average,
hospitalization costs approximately $550 daily, while the current
nightly hotel rate is about $32. After the program officially
got under way in early FY 94, 1,401 inpatient days were avoided
during that year through the hotel lodging program. The lodging
program costs the medical center $43,030, whereas the hospitalization
of these patients would have cost $770,550. Thus, the program
saved the medical center $727,520.
Contact Person: Connie Standiford, MD
Service: Ambulatory Care Service
Facility: Ann Arbor, MI VAMC
Number: (313) 761-7975 or FTS (700) 374-5100 Ext 7975
Medical and surgical care of non-healing ulcers at the Dallas
VA had been fragmented between the emergency room, surgical clinics,
spinal cord injury nurses, medical evaluation clinic, and Rehabilitation
Medicine Service. There was virtually no continuity of care, and
patients often went months between episodes of wound care. The
result was often an infected wound that was beyond salvage.
In July 1992, an intensive effort was begun to improve the overall
clinical management of patients with non-healing ulcers. A comprehensive
multi-disciplinary wound care team was established, consisting
of a general surgeon, a vascular surgeon, a podiatrist, a nutritionist,
two nurses skilled in wound care, and an Orthotic Shoe Technician
from Prosthetics Service. The team members see patients one day
a week and address all issues relating to the healing of ulcers.
Due to the limited number of patients needing this intensive approach,
a patient may be seen each week if indicated.
Benefits
The rapid healing of ulcers, which in many cases had been present
for years, was immediately apparent. However, our the primary
measure of success was the number of below the knee amputations
(BKAs), an important and easily measured outcome parameter.
The number of below the knee amputations performed at the Dallas
VA from 1990 to 1995 is shown below. If the rate for January through
December 7 continues, 79 amputations will be performed by the
end of calendar year 1995. This would represent a reduction of
69 amputations from the 145 performed in 1990. Since our average
length of stay for a BKA is 43 days per patient, this equates
to avoiding 2,838 days of hospitalization in 1995 as compared
to 1990.
Contact Person: Mark S. Nelson, MD
Service: Ambulatory Care Service
Facility: Dallas, TX VAMC
Number: (214) 372-7010 or FTS (700) 749-5135
Health care workers are often challenged to provide care for patients
who obstruct treatment, behave in violent or abusive ways, or
seek multiple prescriptions and unnecessary drugs, often for resale
on the streets. In the past, frustrated providers, at their wits
end, have either done the minimal amount to "get rid"
of difficult, dangerous, and drug-seeking (3-D) patients or simply
refused to provide care.
The Portland VAMC's 3-D program was designed to deliver safe and
appropriate health care, while reducing the frequency of incidents
involving these patients. The 3-D program tracks incidents of
threatening, assaultive, uncooperative, and drug-seeking behavior
in the medical center, provides multidisciplinary clinical review,
advises and trains providers to manage 3-D problems, clarifies
to patients the behavior consistent with safe care, and informs
potential providers of a patient's special needs and the plan
to provide consistent care without tolerating disruptive behavior.
Rather than telling 3-D patients to "go away," we tell
them, "Come here, within these behavioral limits, for safe
and appropriate care."
Benefits
The program has empowered our front-line health care providers
to offer safe and appropriate care to 3-D patients, while reducing
the number of untoward incidents. We have dramatically reduced
violence in our medical center, reduced the number of inappropriate
narcotic prescriptions in our emergency room, and arranged less
fractionated, more coherent care for patients. A study of 36 violence
prone patients showed that the number of violent incidents decreased
from 47 the year before to four the year after 3-D care plans
were instituted. Narcotic prescriptions in the Emergency Room
went from 16 to 0 per year for a sample of 21 drug-seeking patients.
The average number of different physicians involved in the care
of difficult patients decreased by 26% and the average number
of days in the hospital decreased by 51%. Our medical center realizes
an average savings of $7,400 per year per patient managed through
this process.
Staff morale has improved as a result of this program. Providers
are more willing to report problems, rather than assume violence
and abuse are part of their job. They are also more willing to
work with challenging patients, knowing that they are part of
a team that is trying to solve a problem. Most important, our
patients are getting good medical care in a setting of safety
and consistency. As one veterans service officer, a tenacious
advocate for patient's rights, said when a patient hesitated to
sign a 3-D health care plan, "David, sign it. It's a good
deal. Heck, if you won't sign it, I'll sign up for myself."
Contact Person: Laurence H. Baker, Ph.D.
Service: Psychology Service
Facility: Portland, OR VAMC
Number: (503) 721-1039 or FTS (700) 424-1039
P reviously, clinicians had to flip through the entire medical
record to obtain data on an outpatient; in particular, it was
often difficult to find information regarding vaccinations, the
last physical examination, and procedures that had been performed.
Working with IRM, a health summary was developed for each clinic
that includes the specific data needed for that clinic. The first
page of the print-out includes monitoring information such as
the date of the last physical examination and vaccine history.
All medications are listed along with laboratory values and procedures
that are significant to that clinic. If the patient is on a medication
such as warfarin, the date and value of the last prothrombin time
and information about the last dosage adjustment is also printed.
Prior to the clinic, a medical clerk prints health summaries for
each patient scheduled for the clinic that day by entering the
name of the clinic and the date. The clerk then puts the summary
on the front of the medical record prior to the clinician seeing
the patient.
Benefits
Clinicians have much of the information needed to see the patient
readily available, cutting down the time spent leafing through
medical records. The monitoring information quickly indicates
patients who need a physical examination, an update or booster
on their vaccines, or a particular laboratory test to monitor
one of their medications.
Contact Person: R. Bowen
Service: Medical Service
Facility: Danville, IL, VAMC
Number: (217) 442-8000 Ext. 5283 or FTS (700) 951-5283
As a tertiary care referral site, Ann Arbor VAMC provides specialty
care to patients from Battle Creek and Saginaw VAMCs and the Grand
Rapids and Gaylord Outpatient Clinics. In the past, these facilities
sent consult requests via driver or mail to Ann Arbor for scheduling.
In an effort to improve processing time, the faxing of requests
was tried. While it reduced the delivery time, faxing required
staff time on both ends to transmit the requests and assure that
they were legible. More important, the process still involved
a substantial delay for return of the consult with the appointment
date, notification of the patient, and transfer of the record.
An additional problem was the incomplete data on patients who
were not already in Ann Arbor's database.
We proposed that access to Ann Arbor's DHCP database be given
to referral clerks and other designated staff at each referral
site so that they could schedule patients directly into Ann Arbor
clinics. At the same time they could make sure that the data were
complete for each patient scheduled. The referral sites agreed,
and their staff were trained by Ann Arbor personnel. Beginning
in March 1995, all patients who would previously have been scheduled
by Ann Arbor MAS staff were scheduled directly by the referral
sites.
Benefits
Contact Person: Jeanette Ventura
Service: Medical Administration Service
Facility: Ann Arbor, MI VAMC
Number (313) 769-7100 Ext. 5261 or FTS (700) 374-5261
T he present organization of the medical center aligns employees
hierarchically within services. Ambulatory care nurses and clerks
look upward within the service hierarchy for guidance on how to
function within their clinics. While this organization fosters
uniformity across clinics, it impedes the coordination between
services required to adapt to the unique needs of differing clinics.
We piloted Clinic Based Management Teams (CBMTs) to empower clinic
staff to collaborate in managing each clinic to meet its special
requirements. Each clinic's CBMT includes clinic clerks, clinic
nurses, the clinic Chief or designee, a representative from the
Ambulatory Care Management Team, and representatives from other
disciplines involved in the clinic (pharmacists, respiratory therapists,
social workers, etc). The team's mission is to improve the quality
of care and the quality of the patient's experience in the clinic.
The team has ownership of the following issues: clinic space,
work hours, patient flow, stocking and equipping of exam rooms,
and managing clinic delays. The CBMTs are encouraged to resolve
all problems that are within their scope. They report to the Ambulatory
Care Management Team consisting of the ACNS/Nursing, Chief AC&P,
and HSS/Ambulatory Care. Problems outside the team's scope are
communicated to the Ambulatory Care Management Team for action.
In early 1996, the medical center plans to take an additional
step toward integration of outpatient services into a comprehensive
ambulatory care program organized along product lines. Each clinic
will function as its own organizational unit, with the Office
of the ACOS/Ambulatory Care providing centralized leadership and
coordination for the program. Clinic clerks will be transferred
to the Ambulatory Care Service. Nurses will remain in Nursing
Service, but will have a more formalized matrix relationship to
Ambulatory Care.
Benefits
The CBMTs were piloted in the Orthopedics, Walk-In, General Medicine,
Infectious Disease, and Pulmonary clinics. While data are not
available to measure improvement, clinic staffs have responded
positively and a number of process improvements have been recommended
and implemented by the teams. Several other clinics have requested
inclusion in the next stage of implementation.
Contact Person: Jennifer Leeman, HSS/AC
Service: Ambulatory Care Service
Facility: Durham, NC VAMC
Number: (919) 286-6963 or FTS (700) 671-6963
Quality improvement monitors revealed that patients presenting
with chronic vascular ulcers but admitted for other medical problems,
were occasionally discharged without follow-up appointments for
management of their ulcers. While addressing this issue, we noted
that many patients followed in the Vascular and Surgery Clinics
for chronic vascular ulcers and non-healing wounds could appropriately
be managed by advanced practice nurses who had wound care expertise,
were operating within defined protocols, and had access to attending
physician consultation.
In April 1994, a Wound Management Clinic (WMC) was established
for the outpatient management of patients with chronic vascular
ulcers and non-healing wounds. Patients are referred from other
outpatient clinics and from inpatient settings at discharge. WMC
staff also provide consultation for patients managed by the Home
Based Health Care program and Community Nursing Home Care coordinators.
The clinic is staffed by two Clinical Nurse Specialists who are
also responsible for inpatient wound care programs, a Registered
Vascular Technologist, an LPN from the Ambulatory Care staff,
and two attending physicians from Gerontology and Surgery Services
who serve as consultants. Wound management protocols developed
with physician concurrence are used to direct clinic operations.
The clinic is held one afternoon a week at the same time as the
Surgery and Vascular Clinics in an adjacent space; this arrangement
facilitates patient referrals between clinics. Patients returning
to Vascular or Surgery Clinic appointments are also routinely
scheduled for the WMC, allowing staff from both services to examine
the patient's progress and develop an integrated interdisciplinary
plan of care. Patients are provided with telephone numbers to
contact WMC staff regarding changes in wound status or other patient
concerns. To decrease the number of appointments for patients
scheduled in another clinic, WMC staff arrange to see patients
outside regular clinic hours.
Benefits
The WMC has demonstrated improved efficiency and positive clinical
outcomes, with 77% of chronic patients achieving a healed wound
status. The waiting time for a WMC appointment is one week, compared
to prior waits of several weeks for a Vascular or Surgery Clinic
visit. Patients have expressed great satisfaction with the clinic's
accessibility and continuity of care. Using advanced practice
nurses to manage stable patients with chronic wounds has also
allowed Vascular and Surgery Clinic physicians to see more patients,
resulting in decreased waiting times for these clinics as well.
Finally, the Clinical Nurse Specialists are able to follow patients
for whom they managed wound care on an inpatient basis.
Contact Persons: Pamela Leugers, MS, RN, CS; Susan Thomason, MN, RN, CS;
Lynn Payne, RN, BS, RVT; Mary Cochran, LPN; Claudia Beghe, MD; and
Ariel Rodriguez, MD
Service: Nursing Service
Facility: Tampa, FL VAMC
Number: (813) 822-7541 or FTS (700) 822-7541
The Pharmacy and Therapeutics Committee established a subcommittee
to review all long-term users of narcotic analgesics. Patients
who have been prescribed narcotic analgesics for three or more
consecutive months are identified through a computer generated
drug search. Each patient's physician is notified and asked to
provide justification for the continued use of these medications.
The justification is reviewed by the subcommittee, and a determination
regarding the appropriateness of continued use of the narcotic
analgesic is made.
Those patients for whom continued use of narcotics is determined
not to be appropriate or who have not had a therapeutic trial
of alternative pain management are offered two options: admission
for inpatient detoxification or outpatient detoxification. Patients
choosing outpatient care are referred to a Pain Management Clinic
staffed by a clinical pharmacy specialist. They are detoxified
from narcotic analgesics and treated with various combinations
of NSAIDs, non-narcotic analgesics, skeletal muscle relaxants,
antidepressants, and antiepileptics. The clinical pharmacy specialist
provides close follow-up, and medication adjustments are made
as needed.
Benefits
As of October 1995, 129 long-term narcotic users had been identified.
Fifty had a diagnosis of terminal cancer or another severe end-stage
diagnosis and were continued on their narcotic analgesics. The
other 79 patients were successfully detoxified. The majority experienced
adequate pain relief with alternative pain therapy; 22 did not
and had their narcotics reinstated.
Contact Person: Sam Fox, Pharm. D.
Service: Pharmacy Service
Facility: Salisbury, NC VAMC
Number: (704) 638-2921 or FTS (700) 699-2921
Chronic pain patients seeking narcotic renewals through the Walk-In
Clinic were a major issue for our Ambulatory Care staff. The staff's
concerns were poor continuity of patient care, lack of unambiguous
plans relating to a patient's long-term pain management, possible
drug-seeking behavior and addictions, and the gate-keeping role
of staff. In addition, patients would sometimes become verbally
abusive and threatening to the staff when denied narcotics. It
was clear that patients needed a systematic method of obtaining
pain medication renewals, and staff needed guidelines for managing
patients with chronic pain.
A Chronic Pain Medication Program was established which requires
patients to enter into a written contractual agreement with their
clinician regarding when and how they will receive medications
and how changes in their prescriptions will be made. The objectives
of the program are to minimize drug use, maximize the effectiveness
of pain medications, and reduce patient frustration and waiting
time for renewing medications.
The majority of patients are placed on a pain cocktail which is
individually tailored to maximize pain relief. The cocktail vehicle
is used to mask its contents as patients are not told which medications
they are receiving. This approach enables the clinician to alter
the contents of the cocktail without undue stress for the patient
and to use placebo effects to assist in pain relief.
Patients agree to call the Ambulatory Care Nurse Coordinator seven
days before the renewal date to request their pain medication.
The prescription is then filled and available for pick-up at the
Pharmacy when the patient arrives. Those patients who are disabled
or reside a significant distance from the hospital may receive
their medication by certified mail with a signed receipt returned
to the Pharmacy. Initially, there was a great deal of manipulative
behavior by patients to receive their renewals early. However,
this has diminished as program staff have been firm about keeping
patients to the prescribed schedules.
Benefits
Currently, there are 147 patients enrolled in the Chronic Pain Clinic Program. More than 95 of the 295 patients who entered the program have been titrated off pain medications. Patients receive their refills as scheduled and are satisfied with the
program. Walk-In Clinic staff are no longer gate-keepers for requests
for pain medication renewal and are able to focus on medical issues.
Contact Persons: Dee Daugherty, MSN; Tesfai Gabre-Kidan, MD; and
Charles S. Paxson, MD
Service: Ambulatory Care Service
Facility: American Lake Division/Seattle, WA VAMC
Number: (206) 582-8440 Ext 6228 or FTS (700) 396-6228
We learned that the monitoring of laboratory values for patients
receiving warfarin needed improvement through a drug usage evaluation.
We decided to use DHCP to automatically screen for appropriate
laboratory monitoring prior to dispensing prescriptions for warfarin.
Upon entry of a new or refill warfarin prescription, the locally
developed software checks the laboratory package to see if an
INR has been done in the past 45 days. If so, the software will
allow dispensing of the prescription. If not, the package will
take the following actions:
Benefits
The software program is being implemented at this time. Anticipated
results are better anticoagulation management with fewer adverse
drug events and fewer hospitalizations.
Contact Person: Eva Fowler, R.Ph.
Service: Pharmacy Service
Facility: Carl T. Hayden VAMC, Phoenix, AZ
Number: (602) 222-6427 or FTS (700) 761-6427
C OPD was the most common diagnosis for medicine patients in the
Emergency Room/Urgent Care Center (ER/UCC) during 1993 and 1994.
In reviewing the care provided to COPD patients, several concerns
emerged. First, ER/UCC staff felt that COPD patients were not
triaged quickly enough, causing some patients to deteriorate while
waiting to be seen. Second, patients frequently came to the ER
with advanced bronchospasm because they were not identifying and
appropriately managing their COPD. Finally, only 12% of patients
receiving treatment for COPD in the ER/UCC were given a bronchodilator
by metered dose inhaler (MDI) as their first intervention, despite
literature showing that metered dose inhalations are less costly
than nebulizer treatment and equally effective.
The following actions were taken to address these three concerns:
Benefits
Data were collected for 12 months from January 1994 to December
1994. Analysis showed that patients are now triaged uniformly
and that there were no incidents of COPD patients deteriorating
in the waiting room. Initial treatment is also more uniform now,
and staff members are consistently educating patients in the use
of peak flow meters and MDIs with an aerochamber. However, only
46% of patients achieved a therapeutic response and were discharged
home in two hours, which is the standard we established. This
finding raises questions about the appropriateness and effectiveness
of the MDI protocol for our patient population, an issue which
is currently being assessed.
Contact Person: Sunita Baxi, MD
Service: Medical Service
Facility: San Diego, CA
Number: (619) 552-8585 or FTS (700) 552-8585
T he clinical guidelines recently published by the Agency for
Health Care Policy and Research (AHCPR) estimated that as many
as 50% of surgical patients and 80% of cancer patients experience
inadequate pain management. A survey of subspecialty clinics within
our VAMC revealed that more than 3,000 visits a year were for
chronic pain management, not acute subspecialty care. We addressed
these critical issues through the expansion of both our outpatient
clinic and inpatient pain services. The Chronic Pain Management
Clinic (CPMC) opened in January 1995 and was followed in April
by the establishment of the Acute Pain Service (APS).
The CPMC joins with the Anesthesiology Pain Clinic (APC) and Physical
Medicine and Rehabilitation to provide pain relief services to
veterans five days a week. The CPMC is staffed by a nurse practitioner
who maintains a very close collaborative relationship with the
physicians in the APC. The nurse practitioner provides treatment
services for the relatively stable patient who has a physician
completed work-up for the nociceptive complaint. Treatment includes
medication management, transcutaneous nerve stimulation, hypnosis,
biofeedback, and stress management. A comprehensive multidisciplinary
approach includes Physical and Occupational Therapy, Psychology,
Psychiatry, and Social Services. The total number of yearly visits
in the CPMC is anticipated to be 2,100 by 1996.
The APS provides a full range of analgesic options for inpatients.
While this service was initially intended for post-operative pain
management, patients with acute pain from other etiologies and
hospice patients are also eligible. This service provides a wide
range of treatment modalities, including neuraxial (epidural and
intrathecal) opioids, patient controlled analgesia, and various
nerve blocks.
Benefits
From January 1995 to May 1995, 300 patients were transferred from other clinics to the Chronic Pain Management Clinic, resulting in decreased waiting time for the Orthopedic, Neurosurgery and other specialty clinics, significant improvement in operating efficiency, and a significant reduction in health care costs. The more personalized approach made possible by use of a nurse practitioner in the CPMC has enhanced the continuity and efficiency of health care delivery and improved patient and family satisfaction.
The Acute Pain Service specifically addresses the issues raised
by the AHCPR guidelines with a targeted health care delivery mechanism.
Multiple studies have demonstrated that cost effectiveness, improved
outcomes, and increased patient satisfaction result from the use
of the nociceptive management modalities employed by the APS.
Contact Persons: W.T. Schmeling, Ph.D., MD; S. Burchman, MD; S.E. Abram, MD; A. Maitra, MD; M. Larcheid, FNP and D. Miller, RN
Service: Anesthesia Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 Ext 2417 or FTS (700) 383-2417
T he Columbia VAMC participated in a national research project
in 1994 examining patient education related to advance directives.
The investigator interviewed 150 patients at the hospital: 75
inpatients and 75 outpatients. One of the findings was that outpatients
were far more comfortable and prepared to discuss advance directives
than were inpatients.
A clinic was developed which provided outpatients an opportunity
to meet with a social worker to discuss advance directives. Veterans
can schedule an appointment to meet with the social worker in
between their other appointments or may call the social worker
for more information. Signs and posters have been placed around
the hospital and brochures distributed to publicize the clinic.
Benefits
Approximately 150 outpatients were seen in the Advance Directives
Clinic between its inception in February 1995 and October 1995.
These patients and their care providers benefit when the patient
is subsequently admitted: the patient does not have to face these
difficult issues at a time of emotional vulnerability, and valuable
staff time is saved that can be used to provide needed inpatient
services such as discharge planning. The hospital is also effectively
fulfilling its obligations under the Self-Determination Act.
Contact Person: Laura Krejci, MSW
Service: Social Work Service
Facility: Columbia, SC VAMC
Number: (803) 776-4000 Ext. 7696 or FTS (700) 776-4000 Ext. 7696
At the Grand Junction VAMC, Orthopedics, ENT, and Urology clinic
services are provided by consultants. Appointment availability
is two to three months. To gain maximum use of the consultants'
time and to enable them to initiate a plan of care at the patient's
first visit, for each of these clinics we developed an algorithm
that prioritizes patients based on their condition and indicates
the work-up needed for each diagnosis. All requests for a consult
to a subspecialty clinic are reviewed by the RN assigned to that
clinic. Using the clinic's algorithm, he or she determines an
appropriate time for the appointment and schedules additional
tests needed for the work-up so that the results are available
for the appointment.
The nurse also reviews each patient's chart two to three days
prior to the clinic and takes the following actions:
The physician consultant works out of two to three exam rooms
with the facilitating nurse directing work flow. The nurse escorts
the patient to the room, places the x-rays on the view box, opens
the chart to the last visit, and prepares the patient for the
exam. When the visit is completed, the physician presents the
chart to the facilitating nurse for any pre-operative teaching,
patient education, referrals, etc. and continues to the room marked
"NEXT."
Because of the success of the program, we have recently begun
to use a modified version for our in-house clinics.
Benefits
*Reflects the removal of all patients referred to the ENT Clinic
for "hearing loss," unless referred by the audiologist.
Contact Person: Gayle Saunders, RN, BSN, CNOR
Service: Nursing Service
Facility: Grand Junction, CO VAMC
Number: (303) 242-0731 Ext. 2180 or FTS (700) 322-0183
While DHCP is an excellent reservoir of clinical information,
it has some disadvantages: much of the data is in separate categories
or menus, retrieving data requires multiple keystrokes, trends
are not often evident, and abnormalities are not highlighted.
A few years ago, Boise VAMC submitted a successful proposal to
the Western Region to develop a personal computer (PC) local area
network (LAN) that would interact with DHCP. This proposal led
to the Education Utility and Clinical Information Database (EUCLID),
which is essentially an electronic medical record with interactive
on-line information, designed to improve quality, lower costs,
and enhance productivity.
Data from DHCP are extracted by serial exchange into a Windows
based graphic user interface. Similar data are grouped together.
The last four values are displayed to identify trends and are
highlighted in red if abnormal, or magenta when trending. Sections
exist for demographics, laboratory results, outstanding orders,
medications, cultures, imaging studies, diagnoses, and electronic
documentation of care, e.g., discharge summaries, histories and
physicals, and electronic progress notes.
Double clicking on a laboratory value or medication opens a hypertext
help window to access a wealth of reference data. Further help
is available by exiting to a second level that allows access to
24 CD-ROMs with several standard textbooks of medicine, management
manuals, AHCPR clinical practice guidelines, Medline literature
search capabilities, full journal text of several recent journals,
and the Iliad expert diagnostic system. Further patient data are
available by accessing DHCP itself. Application software (Microsoft
Office and Harvard Graphics) are also on line. Scanning in ECGs
and other medical images has been successfully pilot tested. All
of the information can all be accessed as an SQL database, allowing
correlation of variables of interest.
Action profiles have been enhanced to include additional information,
e.g., for digoxin prescriptions, potassium and creatinine values
and the digoxin level are displayed. A column is used to display
less costly alternative medications; selecting the alternative
is just as easy as checking off the refill, but the clinician
still has the choice. Medications are also bar-coded.
Benefits
Providers enthusiastically use the system. Access to information
that highlights abnormal laboratory values is helpful in rapid
establishment of some diagnoses. Ready availability of information
appears to improve diagnosis and treatment. In addition, patients
are aggregated in ways that save clinicians from keeping several
lists. For example, one's own clinic patients are available by
appointment date or alphabetically, and ICU patients can be displayed
at the touch of a button.
Bar coding medications saves 5 to 10% of outpatient staff pharmacist
time. The alternative medication suggestions save at least 10%
of the outpatient pharmacy budget. Clinician acceptance of the
suggested alternatives is high because of the non-coercive way
in which they are presented and the on-line educational material
which can be easily referenced.
Contact Person: David Lee, MD
Service: Chief of Staff
Facility: Boise, ID VAMC
Number: (208) 338-7201 or FTS (700) 554-7201
We noticed that some ambulatory care patients were not compliant
with prescribed medical regimens and often had repeated visits
back to clinics before their next scheduled appointment due to
destabilization of health status. Of particular concern were patients
with diabetes, hypertension, those undergoing anticoagulation
treatment, and those being treated for tuberculosis.
Four nurse-operated outpatient clinics (one for each diagnosis)
were established in 1992, using RNs to manage the care of these
patients. All patients have had prior assessments and treatment
plans completed by their primary physician and orders written
for their treatment regimens. Referrals are made by the primary
physicians or Medical Clinic RNs for follow-up management in these
clinics. Using protocols, regular follow-up practices have been
established for each diagnostic category. Since none of the RNs
in these clinics are advanced practice nurses, a physician signature
is obtained for each patient activity that requires a physician's
order, e.g., x-rays, laboratory work, medication adjustment, etc.
The clinics are conducted by RNs who previously worked in the
Medical Outpatient Clinic. They are held in the same physical
space and at the same times as the Medical Clinics so physicians
are readily available for consultation and orders. No additional
FTEE or space was required. Patient and family education and repetitive
reinforcement of patient treatment activities are a large and
important part of the clinic. The nurses are available by telephone
for patient consultation during administrative work hours.
Benefits
The number of patients enrolled in the Nurse Managed Clinics has
steadily increased every quarter over the past three years. There
has been a reduction in the number of patients returning to their
Medical Clinics prior to their next appointment, and surveys have
indicated increased patient satisfaction. Physicians were originally
resistant, but have become enthusiastic about the clinics and
have been sending increasing numbers of referrals.
Contact Person: Carol Wermuth, MSN, MBA, RN
Service: Nursing Service
Facility: Chillicothe, OH VAMC
Number: (614) 773-1141 Ext 7365 or FTS (700) 975-7365
In 1991, we asked staff and resident physicians in our General
Medicine Clinic about clinic operational issues. When we reviewed
the list of personnel needs that were identified, we determined
that almost all of the functions could be performed by non-nursing
staff. We developed positions for Medical Assistants (MAs) and
trained them to fill these needs in the clinics. The MAs were
certified to perform arterial and venous punctures, spirometry,
cerumen removal, and exercise electrocardiography. They also support
the nursing staff in transporting patients, obtaining and retrieving
records, and entering laboratory orders into the computer system.
Benefits
To assess the impact of the MAs, we interviewed patients and collected
data before and after the development of this new position. Waiting
time in the laboratory drawing area was reduced from 13 minutes
in 1992 to 9 minutes in 1994. The interval between the appointment
time and the time the patient was seen by a physician decreased
from 29 to 26 minutes. The time physicians spent with the patient
in the examination room decreased from 35 to 26 minutes, and the
overall clinic visit time was reduced by three minutes.
Contact Persons: Lisa J. Cochran and Traci Fox
Service: Ambulatory Care Service
Facility: Portland, OR VAMC
Number: (503) 721-7897
Until June 1993, the medical service at the Walla Walla VAMC was
organized into separate inpatient and outpatient services with
physicians assigned exclusively to one or the other. Outpatients
were treated in a busy clinic that attempted to have patients
see the same outpatient physician at each visit; however, patients
often saw numerous physicians over a period of time. Patients
also often interacted with many nurses and clerks during a single
visit and waited in long lines at a centralized check-in desk.
When a patient was admitted, an inpatient physician was assigned
on a rotation basis; thus, patients usually had a different physician
for each admission. Staff turnover was high and satisfaction low;
limited resources and increasing workload demanded that we do
more. A multidisciplinary process action team was chartered to
develop a system in which one physician provided both inpatient
and outpatient care to an assigned group of patients.
After months of careful design by the process action team, the
Private Practice Model was implemented in June 1993. Each veteran
was assigned to one of four primary care teams, each consisting
of two physicians, two registered nurses, and a clerk. Each physician
has a primary caseload of 600 to 700 patients for which he provides
inpatient, outpatient, and NHCU care. The team operates as a joint
practice in which one physician covers the other's patients during
any absence. The RNs provide patient care during clinic visits,
serve as the patient's telephone contact person, and ensure continuity
of care for their group of patients. With the opening of the Ambulatory
Care addition, we now have 0.5 social workers assigned to each
team and a clinical dietitian available in the area.
Benefits
| Ratio of Admissions to Outpatients Visits | ||
| Percent of Visits that are Unscheduled | ||
| No Shows for scheduled appointments (Medicine) | ||
| Waiting time to schedule new appointments | ||
| Clinic waiting time |
In addition, the average daily census for Medical Service has
dropped to 13.3 in FY 1995 from 26 in FY 1992 and 20.4 in FY 1993.
Staff turnover has also declined for all disciplines.
Name: Winifred Graham, RN and Angela Stevenson, RN
Service: Nursing Service
Facility: Walla Walla, WA VAMC
Number: (509) 525-5200 or FTS (700) 434-2594
T he firm system was implemented in the medical services at Lakeside
VAMC and at Northwestern University Medical School in 1990. However,
this re-organization affected only inpatient care at Lakeside.
Lack of an ambulatory care component impeded the delivery of care:
continuity was lacking, patients were often unable to identify
their provider, unscheduled care was managed in the ER/Triage
area, and patients requiring close follow-up in the ambulatory
setting were often seen by a different provider at every visit.
On July 1, 1994, after more than one year of multidisciplinary
planning, the ambulatory firm system was implemented and integrated
into the existing system. Each of the three firms were structured
to provide longitudinal care, interim care, and unscheduled care.
Although longitudinal care is the primary function of the firms,
the other two components provide improved continuity of care:
Interim care involves the frequent, close monitoring of patients
between visits to the primary care physician or following hospital
discharge; unscheduled care allows patients to have quick access
to care outside the ER/Triage setting with the care provided by
clinicians familiar with them.
To provide these three functions, staff from multiple services
were selected to join the firms. Nine full-time general medicine
attendings, 61 medical residents, nine nurses, three clinical
pharmacists, three dietitians, three social workers, and six MAS
staff were distributed equally across the firms. In addition,
an ambulatory block rotation was developed which involved two
medical residents per firm per month. At each of its half-day
clinics, each firm usually has two medical residents on block
rotation, two to three other medical residents, a clinical pharmacist,
a nurse case manager, and two precepting attending physicians
managing all three functions. The medical residents not on block
rotation provide longitudinal care. Unscheduled care is handled
by a block rotation resident and attending preceptor. Interim
care is provided by the other block rotation resident, the clinical
pharmacist, an RN case manager, and a precepting attending physician.
To improve communication between providers, a log book of patients
is maintained for the interim area; it is used to record the specific
problems and target goals of the patients scheduled. Acting as
a liaison between the inpatient and outpatient components of the
firm, the RN case managers make rounds on the inpatient wards
twice per week and see these patients in the interim area if rapid
follow-up is needed.
Benefits
A pre-post patient survey demonstrated a statistically significant
13% increase in the proportion of veterans that rated their care
good to very good. There was a 20% increase in the proportion
of veterans that knew the name of their physician. Medical resident
and staff satisfaction surveys revealed that both were pleased
with firm implementation. Further, they believed that care was
good and had improved since implementation. Medical residents
were positive about the changes in the educational environment
and the support of precepting attending physicians. Following
implementation, longitudinal care visits increased by 14%; the
total number of unscheduled visits to the facility increased by
13%, while the number of patients seen in the ER/Triage area dropped
by 46%. Consequently, we have increased the amount of care provided,
improved the continuity of care, improved patient and staff satisfaction,
improved the educational environment, and changed the location
in which care is delivered.
Contact Person: Brian Schmitt, MD
Service: Ambulatory Care Service
Facility: Lakeside VAMC, Chicago, IL
Number: (312) 640-2230 or FTS (700) 788-3099
The Dayton VAMC initiated a Prime Care Service to increase patient
satisfaction and provide continuity of care. However, patients
admitted to the hospital are frequently not treated by their Prime
Care physician, leaving a gap in their continuity of care. An
inpatient liaison nurse position was created in the outpatient
Prime Care clinic to help bridge this gap, as well as to assist
inpatient staff physicians in coordinating hospital care. Currently,
two of the four Prime Care teams have established this position.
The inpatient liaison nurse duties are performed by a registered
nurse from each of the participating outpatient Prime Care clinic
teams; the position is rotated among the team's nurses on a monthly
basis.
The inpatient liaison nurse visits all team patients admitted
to the hospital. The initial visit provides the patient with a
contact person from his outpatient treatment team. During subsequent
visits, the liaison nurse reinforces patient education relating
to the disease process and medications, and assists with referrals
to the community health nurse. The liaison nurse also works closely
with the treating inpatient physicians to arrange and follow-up
on referrals to ancillary services, and to identify patients who
would benefit from special outpatient services, e.g., intensive
diabetic education, home health care, or outpatient procedures.
At the time of discharge, the liaison nurse reviews the discharge
medications with the patient and answers any questions he or she
may have. The liaison nurse also ensures that the patient has
a follow-up appointment in the Prime Care clinic and is given
the appropriate Prime Care telephone numbers. The completion of
these tasks by the outpatient Prime Care nurse requires approximately
two hours per day.
Benefits
Continuity of care is improved during hospitalizations, and patients
appreciate seeing a familiar face. The liaison nurse's review
of discharge instructions helps to eliminate potential lapses,
such as omission of discharge medication orders and lack of Prime
Care follow-up appointments, which could result from a Prime Care
patient being admitted to another service. The contact with the
liaison nurse also appears to make the patient more likely to
call the Prime Care team regarding his health care after discharge.
Contact Person: Brenda Moore
Service: Medical Service
Facility: Dayton, OH VAMC
Number: (513) 262-2112 or FTS (700) 950-6511 Ext 2112
A "continuity of care" model of health care delivery
became fully operational at the Marion VAMC in October 1994. Before
then, outpatient physicians were seeing the bulk of patients,
both scheduled and unscheduled, often as many as 40-50 patients
per physician per day. Unnecessary admissions were frequent due
to the inability to comprehensively evaluate each outpatient;
crowding and long waits for outpatient care were common and led
to complaints among both patients and staff; medications and treatment
plans were frequently changed, based on the idiosyncrasies of
each physician's practice; length of stays were extended, unnecessary
tests ordered, and accessibility into the system was at times
next to impossible. An interdisciplinary Quality Improvement Team
was charged by Medical Service with the task of developing and
instituting a "continuity of care" model.
The first of six clinics opened in January 1994, with full implementation
nine months later. Each clinic team has two to three MDs sharing
the responsibility of providing both inpatient and outpatient
care for 800 to 1,000 patients. Each team also has one RN selected
by the clinic physicians and one patient services advisor from
MAS. There has been a realignment of staff within support services
with one clinical pharmacist, one social worker, and one clinical
dietitian assigned to cover two clinics.
Each clinic team has two exam rooms, a distinct waiting/reception
area, and a nursing office; it holds its clinic eight half days
per week, divided appropriately among the physicians on that team,
with both a.m. and p.m. slots for each physician to accommodate
patients' scheduling needs. Weekend rounds are made by one team
physician for all team inpatients. Each clinic team has a color
coded identity, with direct telephone access for the patients
assigned to that team. Telephone triage is used to improve patient
accessibility to the system, decrease the number of unscheduled
visits, and improve timeliness of care.
The clinic teams are self-directed, with responsibility first
to the patients they serve, then to the team itself, and finally
to their respective services. The team approach leads to an emphasis
on patient education and disease prevention. Thursday afternoons
are free of scheduled patients to allow for team meetings, education
of team members, and interdisciplinary patient education clinics.
Benefits
Ninety-six percent of the patients in the Continuity of Care clinics
are seen by their provider within 15 minutes of their scheduled
appointment time. Eighty percent of patients calling for nurse
or physician intervention have their needs met via telephone,
while the remaining 20% are given an appointment to report to
the clinic. The average daily inpatient census for Medicine has
been reduced by 30%, at the same time that we are attracting approximately
100 new patients per month. There has also been a 60% reduction
in "No Shows" for medicine appointments, and the readmission
rate has been reduced by approximately 50%. Patient comments glow
with praise for the new system, and there has been a significant
decrease in the number of patient complaints. Team members have
responded positively to the increased autonomy, and have gained
considerable satisfaction from being accountable to a set group
of patients.
Contact Person: Susan D. Fowler, RN, BSN
Service: Chief of Staff
Facility: Marion, IL VAMC
Number: (618) 997-5311 or FTS (700) 276-0306
After establishment of a primary care program at North Chicago
VAMC, patients were still being seen by non-primary care providers
when they presented to the walk-in area without an appointment.
A survey covering a period of approximately 30 working days found
that only 24% of the "walk-in" primary care patients
were evaluated by their primary care team. Clearly, we needed
to improve the access of walk-in patients to their primary care
providers.
The following actions were taken:
Benefits
To assess the effectiveness of these actions, the proportion of
primary care walk-in patients seen by their team has been periodically
examined. The percentage increased to 92% during our most recent
data collection period. However, as a result of further refinement
and improvement, we believe that 100% of primary care patients
are currently seen by their primary care providers on the same
day that they present to the Triage/Urgent Care area.
Contact Persons: Frank A. Maldonado, MD; and Carol A. Foran, RN
Service: Ambulatory Care Service
Facility: North Chicago, IL VAMC
Number: (708) 578-3770 or FTS (700) 384-4242
All patients in the medical center are assigned to either the
Red, Blue, or Green Academic Global Care Team (AGCT). Each team
sees an average of 2,200 patients per month, with 8-10 new patients
per week. The teams provide or coordinate all of the patient's
medical, subspecialty, surgical, and psychosocial care. The goal
is to establish an integrated, collaborative, health management
plan, coordinated by a single provider, to ensure the optimal
treatment of all of the patient's problems over time. Each primary
care provider has a panel of regularly scheduled "continuity"
patients.
Within each AGCT, "mini-teams" link one team attending
with one nurse practitioner or physician assistant and up to seven
internal medicine residents. Each primary care provider's panel
of patients is cross-covered by other members of the "mini-team,"
and when house staff finish their residency training, their panels
of patients are taken over by incoming residents assigned to the
same "mini-team." The primary care provider assumes
accountability for patient care, regardless of which "mini-team"
member sees his or her patient. The faculty attending physician
assures the quality of care for the entire "mini-team."
Since veterans seeking health care in VA medical centers are known
to have high rates of mental health impairment, a psychiatrist
and a social worker are included on each team. Psychiatrists provide
direct patient care as well as formal and informal consultation
to primary care physicians, and participate in educational programs
designed to increase detection of common mental health problems
such as depression. Social workers provide counseling and case
management.
Physician Team Leaders are responsible for coordinating the health
care duties of the six health disciplines on their teams and the
team's interactions with other medical center services. Team Leaders
work closely with their Team Managers who supervise all clerical
personnel and facilitate clinical care by monitoring patient flow
and handling any patient complaints. The individual discipline's
responsibilities are as follows:
Team Empowerment
When the PACE program was first being developed, a commitment
was made to empower the interdisciplinary AGCTs to do their own
decision-making and to create an atmosphere in which teamwork
and education would flourish. One afternoon per month, scheduled
clinic activities are suspended for each team. During these education
afternoons, the team has case conferences, in-service training
on new policies and procedures, guest speakers, and an opportunity
to discuss and solve team administrative problems. All team members
attend and exchange ideas and share concerns. The monthly education
day reinforces the concept of a team as a problem-solving group
with the power to initiate change.
Team empowerment has meant that the teams are autonomous and have
developed different styles; they carry out PACE procedures and
policies in ways that are most effective and efficient for their
personnel. This is very much in keeping with the plan to empower
the teams to determine their own practices and take responsibility
for their actions.
Matrix Management
In designing an organizational structure for the three AGCTs,
it quickly became apparent that some type of matrix management
system would have to be instituted for the teams to function in
an interdisciplinary manner. A matrix management system is an
organizational structure which empowers two managers from different
organizational units to exercise a degree of supervisory control
over an individual worker. (The concept originated in the 1960's
in large manufacturing corporations where project teams were developed
by assignment of team members from different disciplines or professions).
Matrices have the benefit of linking staff from different disciplines
to a specific team while maintaining linkages to the parent services.
In the PACE matrix, all clinical staff members report jointly
to their physician team leader as well as to their parent service.
The teams (and more specifically their respective team leaders
and administrative team managers) assign and supervise the daily
routine and responsibilities of staff members, including integration
of their clinical activities with the team, scheduling of clinical
activities and vacations, educational responsibilities, etc. The
service, generally represented by an associate chief for the service's
ambulatory care section, is largely responsible for supervising
the professional duties of the staff member through staff development,
service-specific quality assurance, individual reviews, and related
mechanisms.
The exact nature of the matrix varies from service to service
and was negotiated independently for each discipline. Across all
services, the minimum level of control the AGCT exercises consists
of joint recruitment and selection of team staff, rating each
staff member's teamwork, and negotiating work flow directly with
the team member(s).
The matrix is also carried out at the top level of supervision
where practical. The administrative team managers report jointly
to their respective team leaders and to the PACE Operations Officer.
The Associate Chiefs of Ambulatory Care for Nursing, Pharmacy
and Social Work Services report jointly to their parent service
and to the physician Chief of PACE. The three senior internist
team leaders report formally to the Chief of PACE, but also have
a structured relationship, particularly for academic purposes,
with the Chief of Medicine. The same is true for the PACE senior
psychiatrist, who reports to the Chief of PACE and Chief of Psychiatry.
Benefits
Continuity of care has improved. Compared to one year earlier,
more patients reported receiving all or most of their care within
their designated PACE team by 1993 (16.1% increase; p<.01).
The proportion of patients who saw a physician continuously anywhere
at Sepulveda VAMC increased by almost 10% (p<.05), and the
proportion of patients who received continuity of care in PACE
increased even more, by 18.7% (p<.01). When we adjusted for
age, health status, and number of clinic visits in the previous
year, we found even greater differences for each type of continuity
(team, individual provider, and PACE provider) (p<.001).
More patients received scheduled appointments compared to walk-in
care during the pre- compared to the post-PACE period. Percentages
of scheduled appointments rose from 46% in 1991 to 73% in 1992
and 1993.
Assigning all patients in the medical center to one of the three
AGCTs has also greatly improved the handling of patient complaints.
The majority of these complaints focus on a problem the patient
is having dealing with the system, e.g., inability to get an appointment,
lack of understanding of the system, lack of understanding of
treatment plans, etc. Since the teams are "where the buck
stops," both clinically and administratively, patients quickly
learned to go to their Team Managers to get straight answers to
questions, and the teams know how to get the patient through any
obstructing "red tape." Additionally, most patient complaints
that do reach the medical center director's office are such that
they can be referred to the Team Managers for resolution.
To assess the impact of including a psychiatrist and social worker
on each AGCT, we have examined several variables relating to depression.
Fewer patients reported symptoms of depression in 1993 (20.5%)
compared to 1992 (25.8%) (p<.001), but the detection of depression
increased by 23.7% from 1992 to 1993 (p<.05). The increase
in detection of depression was even higher after we controlled
for health status (including mental health symptoms), number of
visits to clinic, and age (p<.001). However, when we accounted
for these factors, PACE patients were no more likely to report
that they had been helped for their depression in 1994 than in
1992 and 1993 (p=.20). Consequently, we have undertaken a major
quality improvement project to improve care for depression in
primary care.
Contact Person: Lugina S. Evans, OTR
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9400 or FTS (700) 966-9400
T he information system in existence during the planning stages
of PACE was the VA's Decentralized Hospital Computing Program
(DHCP). This system, while quite extensive and far reaching in
its scope, was primarily geared towards administrative data collection
and appointment management. It had limited capabilities for ad
hoc queries by end-users against its databases, stored limited
clinical information (essentially only laboratory test results
and medication profiles) and had primitive user interfaces consisting
of roll-and-scroll line oriented information displays. Users had
to enter commands and information into the system in a preset
order as prompted by the system. Generally, it was difficult to
vary this order, to correct erroneous data entry, or to review
or redisplay just viewed information. Though this system has continued
to evolve, it was anticipated that it would not meet all of the
information needs required for PACE without significant enhancement.
Consequently, when PACE was first being developed, an informatics
team comprised of an M.D. informatics expert, a Ph.D. level researcher
with a computer science and operations research background, a
personal computer programmer, a hardware support person, a part-time
DHCP programmer, and a part-time user support person was given
the task of reorganizing our computer information systems to provide
easy access for clinicians and administrators in ambulatory care.
The resulting system is called the Ambulatory Care Information
System (ACIS) and offers a graphical user interface to clerks,
nurses, doctors, and administrators for collecting and reviewing
clinical and operations information. ACIS currently encompasses
Local and Wide Area Network connectivity among roughly 300 IBM
compatible personal computers. These systems exist in multiple
configurations from 386SX-25mhz to pentium machines, with the
majority being 486DX2-66mhz. All run Microsoft Windows or Windows
for Workgroups. Computers are located in examination rooms, attending
offices and conference areas, clinical and non-clinical clerical
and administrative areas, pharmacist offices, and nursing stations.
Machines are connected to one another, to network file servers,
and to the hospital mainframe via class III ethernet and a fiberoptic
backbone, and use the Microsoft Lan Manager Network operating
system. A number of examination rooms are served by pen-based
laptop computers and wireless ethernet links. We currently have
four OS-2 based server systems on the network, managing security
and file access, as well as several Windows for Workgroups data
servers. The network is connected directly to DHCP through fiber,
and workstations communicate with DHCP via Decserver serial connections,
TCP/IP and/or LAT protocols. Gateways on the fiber backbone provide
Wide Area Connectivity to the VA-wide network (IDCU) and to the
UCLA Campus network via T1 links.
New software applications provide accessible and clinically useful
programs that are capable of uploading information from local
Windows-based workstations to DHCP and downloading information
from DHCP to local workstations. The table on the next page provides
a summary of the software applications.
Benefits
The ACIS supplies greatly enhanced tools for analysis of clinic
operations and access to clinical information by providers during
a patient visit. Currently, the complete ACIS is in use at the
Sepulveda and Charleston VAMCs. Various components, especially
telephone triage, have been exported to additional sites. In general,
ACIS should integrate well with any DHCP site. Effective implementation
requires significant hardware investment and probably a half-time
user support person who is proficient with personal computers.
Contact Person: Steven H. Rappaport, MD
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9400 or FTS (700) 966-9400
Medical residents participating in VAMC Northport's Primary Care
(PC) Clinics experience a "managed care" model of coordinated,
comprehensive, and personalized primary care while gaining experience
in direct medical treatment. Recently, the PC staff focused on
improving clinic efficiency, with the goal of reducing the waiting
time for new appointments. Since assessment of resident productivity
might be beneficial in achieving this goal, an instrument was
created to monitor the time residents spend in clinic and the
number of patients they see. The instrument was also designed
to identify the frequency of encounters with patients with specific
medical conditions for the purpose of residency accreditation.
Residents identify the number of patients seen during a clinic
session and the range of primary diagnoses encountered on a survey
form created using the Teleform Software Program. Upon arrival
at the clinic, the resident receives a blank form with the time
of arrival filled in by the clerk. Upon departure, the completed
sheets are handed to the clerk who then marks the time out. Use
of this instrument is explained at the time residents are oriented
to their clinic responsibilities. They are informed that clinic
attendance, which is mandatory, will be monitored, and accountability
required; notification of the Clinic Manager and the Residency
Supervisor is necessary for approval of schedule changes. The
Teleform data is analyzed using a Microsoft Excel Software program.
The number of patients seen per session and per hour and the amount
of experience with various medical diagnoses is tabulated.
Benefits
Initial assessment revealed a need to increase the number of new
patients seen by residents and the amount of time they spent participating
in clinics. This resulted in the opening of additional new patient
appointment slots and the development of a new patient scheduling
mechanism to increase resident productivity and improve the continuity
and efficiency of patient care in the PC clinics. Monitoring of
residents' experience with various diagnoses is also now possible.
Contact Person: Linda Mermelstein, MD, MPH
Service: Chief of Staff
Facility: Northport, NY VAMC
Number: (516) 261-4400 Ext 7910 or FTS (700) 663-7910
When we initiated primary care, each patient was assigned a specific
physician as primary care provider. However, this action by itself
did not fully achieve the goals of primary care, which include
comprehensiveness, continuity, and accessibility. Since many primary
care physicians were not working full-time in the outpatient clinics,
they were often unavailable when their clinics were not scheduled.
Even during clinic hours, physicians were fully occupied attending
to scheduled patients and could not respond readily to patient
concerns that arose between scheduled visits. These limitations
adversely affected the comprehensiveness and continuity of the
care we provided.
To address these problems, a group of primary care nurse case
managers were recruited. Each patient was assigned a primary care
nurse in addition to a primary care physician. The nurses work
with either one full-time physician (equivalent of 8 half-day
clinic sessions per week) or with two to three part-time physicians.
The RNs and physicians work together as teams.
The RN case manager's responsibilities include the following:
A series of practice guidelines are being developed for the common
problems seen in Ambulatory Care. The RN case managers will be
responsible for monitoring compliance with these recommendations
and, in some cases, for initiating interventions. For example,
the RN will monitor compliance with and assist in implementing
recommended preventive medicine practices for diabetic care such
as annual eye examinations and regular hemoglobin A1C's.
Benefits
Evaluation of this system has shown a 20-25% decrease in the number
of walk-in visits. Chart monitoring has shown marked improvement
in regular recording of vital signs, weight, medication use, and
adverse drug reactions. Many favorable comments have been received
from patients as this system provides them with an identified
individual whom they regularly see during their scheduled visits
and who is available to provide assistance at other times. This
is an important development in a system that was often faceless
and difficult to access. Physician reaction has been extremely
favorable as the RN case managers provide the physicians with
an important element of support, allowing them to spend more time
on complex medical issues.
Contact Persons: Michael Mayo-Smith, MD and Marcia Lorang, RNP
Service: Ambulatory Care and Nursing Services
Facility: Manchester, NH VAMC
Number: (603) 624-4366 Ext 6047 or FTS (700) 837-6011
D ata on overall and individual provider productivity are tracked
daily and summarized monthly in an electronically generated management
report. The report is used to examine provider performance and
to identify outliers. Indicators include patients scheduled per
session, patients seen per session, patient no show and cancellation
rates, clinic cancellation rate, walk-ins seen, and provider panel
sizes. The data can be aggregated for an individual provider or
as an overall average for all providers. Since the provider who
actually sees the patient is at times different from the scheduled
provider, our Medical Informatics section recently developed the
capability for our clinic clerks to enter the provider who saw
the patient in a "provider seen" field in DHCP.
Benefits
Examination of the above data convinced us to increase by 30%
the number of patients scheduled per half-day session for each
primary care staff physician. Use of these data has also enabled
us to optimize our scheduling processes to reduce the average
waiting time to the next available appointment in primary care
clinics. The "provider seen" field in DHCP provides
a more accurate accounting of provider productivity; the capability
to electronically generate an automated provider productivity
report saves the many man-hours that would be required to manually
prepare a monthly productivity report.
Contact Person: Kenneth E. Klotz, Jr., MD
Service: Ambulatory Care Service
Facility: Richard L. Roudebush VAMC, Indianapolis, IN
Number: (317) 635-7401 or FTS (700) 332-3057
T he Seattle VAMC developed primary care teams within the General
Medicine Clinic in 1993. With the new emphasis on primary care
providers and teams came the need to be able to readily identify
which team a patient was assigned to. This information needed
to be accessible to many medical center staff even when the medical
record was not available, making a computer based flag or field
in DHCP the most reasonable way to present this information.
A computer option was created under the Patient Inquiry File which
allows input of the primary provider and team responsible for
patient care. The field contains the name and beeper number of
the primary provider and the name and extension of the individual
to be called if the provider is not available. This information
is available in a look-up capability under the patent inquiry
DHCP menu option. For the General Medicine Clinic, the backup
individual is usually the RN working with the team.
The program was automated for patients enrolled in the General
Internal Medicine Clinic (GIMC) and identifies patients, matches
them with their provider and their clinic team, and extracts the
necessary information regarding beeper numbers from the DHCP telephone
directory. Manual input is currently used when providers outside
of the GIMC are assigned primary provider responsibilities. With
the recent identification of subspecialists in Medicine and specialists
in Mental Health as potential primary providers, further automation
is being reviewed. Our plans also include displaying the information
on the screen when patient information is brought up on the computer,
as well as printing the name of the primary provider and team
assignment on action profiles that are used throughout the medical
center.
The program also allows identification of a primary provider's
patient panel. A primary provider database has been created, allowing
providers to review the number of visits in other clinics for
patients within their panel. This database is also being used
to identify patients who do not yet have a primary provider and
to develop strategies for making the most appropriate assignment.
Benefits
This DHCP capability allows staff caring for a patient to readily
identify the primary provider responsible for the patient's care
and facilitates communications with that provider, thus improving
continuity of care. The capability also helps to prevent duplication
of testing, confusion over medications, and unnecessary referrals.
Contact Person: W. Paul Nichol, MD
Service: Ambulatory Care Service
Facility: VA Puget Sound Health Care System, Seattle, WA
Number: (206) 764-2360 or FTS (700) 396-2360
Las Vegas VAMC developed its outpatient POW Program as a primary
care unit, with an interdisciplinary POW treatment team led by
the POW physician, who provides ongoing medical care in addition
to performing the protocol examination. The team of a physician,
psychologist, social worker, and a secretary has remained stable
over the past ten years, personalizing care through long-term
relationships with patients and their families. The patient population
has grown from the initial 25 in 1983 to a current active caseload
of 280; a case management model has helped facilitate this growth.
By virtue of their enrollment in the POW Clinic, former prisoners
of war are enrolled in the Primary Care Unit of which the POW
Clinic is a sub-unit. After admission to the Ambulatory Care Center
(ACC) and screening by the Acute Care Nurse, a new POW patient
is referred to the secretary who serves as the point of contact
for all POWs. If medical attention is needed that day, the POW
is escorted to the Primary Care Unit to be seen in POW Clinic
or, in the absence of the POW physician, by a physician in the
Primary Care Unit. A follow-up appointment, in the latter case,
is made in the POW Clinic. If immediate care is not required,
the first available appointment is made in the POW Clinic. During
the initial contact, the POW is introduced to the social worker/POW
Coordinator and the POW Program Support Group. Clinic procedures
are explained, and a business card with the names and telephone
numbers of primary care providers is provided.
Coordinated, comprehensive care with provider continuity permits
a change in focus from acute care to prevention and wellness.
Ongoing care may include evaluation and treatment by specialists
in the ACC's Specialty Care Unit or in an inpatient setting. In
either case, treatment is coordinated with the POW Clinic, and
the patient is referred back to the POW Clinic for primary care.
Several factors make this program unique. First, the protocol
physician is the primary care provider for all POWs, and the protocol
is made a working part of the treatment record. Second, from the
outset the POW Clinic was identified as a Primary Care Unit, with
an identified multidisciplinary treatment team providing services
for a well defined patient population. Finally, one individual
serves as the contact person and case manager. This function,
along with a telephone triage system, improves accessibility to
and timeliness of needed services.
Benefits
The primary benefit is customer satisfaction: Our POW patients
are generous with their praise of the program and the treatment
team. POWs from other areas of the country frequently tell us
how different our program is from that of other VAMCs and how
much they appreciate the specialized care they receive here.
Contact Person: Wyn Rhys-Jones, MD
Service: Medical Service
Facility: Las Vegas, NV VAMC
Number: (702) 386-3211 or FTS (700) 386-3597
T he Amarillo VA Health Care Network was designed and developed
to improve access to high quality, primary health care for the
70,000 veterans residing in the Texas Panhandle, eastern New Mexico,
southeast Colorado, and southwest Oklahoma and Kansas. The network
consists of the medical center in Amarillo, a satellite outpatient
clinic in Lubbock, TX, a primary care clinic in Clovis, NM, and
community primary care clinics in Memphis, TX and Stratford, TX,
with additional community primary care clinics under development.
Each of these facilities serves as the initial access point for
entry into the network managed care system.
The community primary care clinics involve collaboration between
our medical center and community resources to provide primary
care services to veterans in rural, medically underserved areas.
We made use of the Rural Health Clinic Services Act of 1977 to
develop sharing agreements based on capitation methodologies with
Certified Rural Health Clinics for the primary care of veterans.
To assure the most effective use of limited resources, we evaluated
potential sites using the Needs Assessment Criteria set forth
in M-9, Chapter 9, Change 4, Appendix 9G, "Criteria and Standards
for New Outpatient Services Remote From VA Medical Centers,"
dated May 4, 1992.
From the outset, telemedicine and teleconferencing have been included
in our plans to support the growing number of primary care clinics
in the Network. The medical center purchased and activated two
telemedicine units in September 1994. At that time, the primary
care clinic in Clovis, NM was opened and staffed with a physician
and two nurses. Since telemedicine support of the Clovis clinic
was the immediate need, one unit was installed there, with the
base unit installed at the Amarillo VAMC. Immediate applications
were dermatology and cardiology consults between the general internist
at the primary care clinic and subspecialists in Amarillo, and
the teleconferencing of patient education activities.
Benefits
The Community Primary Care Clinics provide cost-effective, accessible
primary care to veterans living in rural, medically underserved
areas, while enhancing existing community health care resources.
Entering the community as a partner, not as a competitor, prevents
duplication of services and supports the goals of health care
reform. All financial resources are applied to direct patient
care, and funds are adjustable to accommodate fluctuations in
workload. With no capital outlays and no required FTE, the Community
Primary Care Clinics are a viable alternative in the current atmosphere
of shrinking financial resources. Patient satisfaction survey
data have been very positive and enthusiastic.
The rapidly growing patient population in Clovis has generated
a variety of telemedicine specialty consultations and teleconferencing
of educational activities. As a result of this demand and the
realization of additional therapeutic and education uses, we are
hoping to purchase additional telemedicine equipment for support
of the other rural primary care clinics in our network.
Contact Person: Wendell Jones, MD
Service: ACOS/AC Ambulatory Care Service
Facility: Amarillo VA Health Care Network, Amarillo, TX
Number: (806) 355-9703 Ext. 7285 or FTS (700) 735-7285
Since primary care was implemented, patients have been given specific
appoint- ment times to see a provider in the urgent care clinic.
However, 30% of the patients have failed to keep their appointments
or call to cancel. Since our primary care program is striving
to create a long-term relationship with each patient, we decided
that our telephone triage nurse would call patients who did not
keep their scheduled appointment and ask how they are feeling
and why the urgent care appointment was not kept.
Each day the nurse calls those patients that did not keep their
appointments during the previous day and asks, "We missed
you for your appointment yesterday; how are you feeling?"
Some patients respond that they did not need to be seen because
they were feeling better; others say they forgot and need another
appointment. The nurse evaluates the patient's need for additional
treatment and schedules new appointments where appropriate. There
have also been a few patients that were too sick to keep their
appointment and transportation was arranged to bring them into
the hospital.
Benefits
Thirty-seven percent of the patients who have been called made
another appointment; 1% needed transportation assistance to get
to the hospital. Some patients have also been prevented from coming
to the hospital unnecessarily by the telephone triage nurse evaluating
their need for another appointment. The no-show rate has also
been reduced from 30% to 20%. Informal patient response to the
program has been favorable. For example, a conversation overheard
between patients waiting went as follows: "You know things
are changing here, these people really care. They called me at
home when I missed my appointment."
Contact Person: Fran Johnson-Feldmann, RN
Service: Nursing Service
Facility: Washington, DC VAMC
Number: (202) 745-8567 or FTS (700) 745-8567
Northport VAMC provides its patients with coordinated, comprehensive,
and personalized primary care (PC) through four PC teams that
function much like private practices. In the past, patients were
given a direct telephone number to contact their team's clinic.
Their calls were generally answered by the team clerks, who had
a number of other responsibilities including checking patients
in and out. To reduce the volume of telephone calls handled by
the PC team clerks and to provide prompt and appropriate responses
to veterans' calls, a pilot study of a new telephone triage system
was conducted.
Baseline survey data regarding the volume and types of calls received
each day were obtained and analyzed using the "Teleform"
Software Package. Using these data, plans were made for a telephone
triage system in which calls from the patients of the PC teams
would be forwarded to two multi-line telephones in the Central
Scheduling Office. Two MAS triage clerks were trained to receive
and appropriately respond to these calls, with each clerk being
responsible for taking calls for two teams.
Scheduling issues for all clinics are handled directly by the
clerks. Pharmacy calls are transferred to the PC team pharmacist;
calls related to medical questions are forwarded to a nurse (RN)
on the PC team, and other work related or personal calls are transferred
to the appropriate person on the PC team.
A four week trial of the system was conducted, initially forwarding
calls for one team and then for two teams. The number of calls
and the reasons for them were monitored using a Teleform, and
the distribution of calls over time was determined. The satisfaction
of patients, level of stress of PC team clerical staff, and the
reduction of unnecessary clinic visits due to involvement of nursing
staff in telephone triage were also assessed.
Benefits
Overall, the pilot study was quite successful: It showed that
a centralized telephone triage system could provide improved service
while maintaining personalized care. Veterans expressed satisfaction
with the way their calls were handled and the courtesy of staff
(99.5% of respondents positive for both questions). Fifty percent
of the calls were successfully resolved by MAS triage personnel,
reducing the number of calls referred to the PC teams; the great
majority of these involved appointment questions. Use of RN staff
to respond to medically related calls avoided unnecessary appointments;
this occurred in 46% of the calls transferred to RNs.
The PC teams expressed great interest in continuing the new triage
system, and plans are underway to implement the system permanently
for all four teams. The new system also appears to be more efficient.
We plan to transfer four MAS clerks from the PC teams to other
clinics because of the addition of the two telephone triage clerks
to the PC program.
Contact Person: Linda Mermelstein, MD, MPH
Service: Chief of Staff
Facility: Northport, NY VAMC
Number: (516) 261-4400, Ext 7910 or FTS (700) 663-7910
An interdisciplinary team at the Knoxville VAMC has been busy
reinventing the hospital's care delivery system: Recognizing the
need to improve customer service, the team implemented the Telephone
Liaison Care Program in October 1994. This program provides continuous
access to care, meets the VA customer service standards, and supports
the medical center's mission to provide quality care to the aging
psychiatric veteran.
Prior to the Telephone Liaison Care Program, veterans had to travel
great distances to present as walk-ins when they had questions
or concerns. The new program allows patients and their families
to contact the facility by phone to discuss access to care, eligibility,
scheduling issues, medical concerns, and questions regarding medications.
The service is provided 24 hours a day, 365 days a year and includes
an 800 number. To publicize the service, announcement letters
were mailed out with the regular appointment letters and wallet
cards were printed and given to staff and patients. A station-wide
education program was presented for staff at regular staff meetings.
MAS provided the initial staffing for the program, but this was
subsequently changed to nursing staff. At present, over 500 calls
are processed each month. The calls bypass the operator and come
in either on the 800 number or a direct local line. A telephone
care assistant answers the call within eight seconds and requests
the veteran's name, reason for calling, phone number, and the
last four digits of his or her social security number. These data
are put into the DHCP system immediately. We then determine if
the caller is on the rolls, since VA regulations require that
patients not on the rolls be directed to come in to be assessed
in person. Calls are directed according to VA criteria and protocols;
special protocols were developed for depression, suicide, and
acute alcohol intoxication. Since each call is viewed as a potential
walk-in, staff are empowered to schedule appointments to convert
the walk-in to a scheduled visit. Emergencies are directed to
the closest emergency room and 911 number. Other calls are directed
to the appropriate disposition site. If it is necessary to return
their call, patients are told, "We will call you back within
two hours, please stay by your phone." Before hanging up,
the patient's phone number is verified.
Documentation, based on facility developed guidelines, is made
under the Telephone Triage Clinic module in DHCP. The computerized
notes are available to all staff to enhance continuity of care.
The content of the progress notes are reviewed weekly to ensure
appropriateness.
Benefits
The number of calls increased from 189 in October 1994 to 550
in June 1995. While all services on station can receive calls,
most go to the following: Clerk 33%, Nurse 25%, Pharmacy 18%,
Physician 12%, Alcohol Treatment Unit 7%, Social Worker 3%, Psychology
2%. Monthly monitoring examines the number of calls, the distribution
of calls, the time that calls were received, and the number of
inappropriate calls. This information has enabled us to continuously
improve the program.
We examined the relationship between the number of walk-ins, the
number of calls, and patient satisfaction. As the number of calls
increased, the number of walk-ins decreased and customer satisfaction
increased. We have received continuous letters and calls praising
the new service. The most touching is, "You don't know what
it means to know I can reach someone who cares."
Contact Person: Dixie Ribar, RN, MSN
Service: Ambulatory Care Services
Facility: Knoxville, TN VAMC
Number: (515) 842-3101 or FTS (700) 861-6226
Over the past several years, patients have made increasing numbers
of unscheduled walk-in visits to our clinic. As these unscheduled
walk-ins accounted for more than 50% of our patient visits, leaving
limited time for scheduled continuity of care visits, they were
contrary to our mission of managed primary care. In addition,
many patients saw their primary provider during fewer than half
of their visits, and multiple surveys showed that about 60% of
the walk-in visits were unnecessary. To further complicate the
issue, the number of very sick patients appearing as walk-ins
was increasing drastically, as indicated by the increase in ambulance
runs from five per year to five per month over the past four years.
In response to this situation, all patients on the current patient
lists were asked to choose a primary provider. To remind patients
about the importance of this change, signs were posted throughout
the clinic, MAS clerks reminded patients about their primary provider
at each visit, and clinicians gave their professional cards to
patients. We also sent letters to all patients announcing that
Walk-In Clinic, as it had been in the past, was being abolished;
in the future it would be limited to patients who were truly ill.
Patients were told to arrange all of their care through their
primary providers; if they felt sick, they were to call their
provider for guidance.
We also instituted telephone call in time for all Medicine Clinic
providers from 8:00 - 8:30 a.m. During these calls, patients receive
test results, request medicine refills, and ask questions relating
to their health and treatment. Many patients are instructed on
these calls to make an "unscheduled" visit to the clinic
at the time when their doctor will be MOD and thus available to
see them as a walk-in. Over a three month period, 1,680 phone
calls were logged, many of which would have otherwise resulted
in an unscheduled walk-in visit.
Benefits
Walk-in visits have declined by approximately 30% compared to
last year. The use of the Walk-In clinic is more appropriate:
65% of these visits are now for acutely ill patients as opposed
to 40% in 1993. Routine medication issues currently account for
12% of Walk-In Clinic visits, as opposed to 44% in 1993.
T he Telephone Care Program was initiated at the Louisville VAMC
in May 1994 to enable veterans to gain easier access to outpatient
care. The primary goal of the program is to refer outpatients
to the appropriate staff member without multiple transfers and
delays. A telephone coordinator with a clerical background ensures
that patient calls are efficiently referred to the proper person.
Primary care providers are responsible for returning telephone
calls to patients during the same business day.
IRM developed a local file written in MUMPS to prompt the collection
of and document and track the information necessary for the Telephone
Care Program. Using the computer program, the telephone coordinator
enters the patient's name; this automatically displays the patient
inquiry screen. The coordinator then inputs the type of problem,
status, chief complaint, and to whom the patient's call is being
referred. Subsequently, the provider indicates the resolution
of the patient's problem, e.g., medication refill, advice given
by provider, administrative information provided, appointment
made, test results communicated. Trend reports have also been
developed that allow the tracking of calls per provider, per chief
complaint, and per type of resolution.
Patients who call may be told to report to the Primary Care Clinic
on the same day. To ensure that these patients are seen promptly,
one 20-minute appointment is set up per hour for each provider
to accommodate patients coming in as a result of the Telephone
Care Program.
Benefits
Emergency room visits have declined from over 26,000 in FY 1992
to a projected 23,000 in FY 1995. In addition, the average waiting
time in the emergency room was 1.75 hours in March 1995 compared
to 2.3 hours in FY 1992. Waiting times are also continuing to
decrease in the Primary Care Clinic as a result of veterans utilizing
the Telephone Care Program. In March 1995, the average waiting
time for the Primary Care Clinic was only 18 minutes.
Contact Person: Marylee Rothschild, MD
Service: Ambulatory Care Service
Facility: Louisville, KY VAMC
Number: (502) 894-6880 or FTS (700) 548-5047
Virtually all VA hospitals are struggling with the difficult issue
of excessive delay in obtaining appointments to outpatient clinics.
This is especially true at the large tertiary referral centers
that receive consults from a number of smaller hospitals. In 1992,
we began to notice an increase in the number of days to the next
available appointment in many subspecialty areas. As a tertiary
referral center for several smaller VAMCs in Texas, our number
of consult requests for subspecialty evaluation was steadily increasing.
We developed an aggressive initiative to address this problem.
It is based on the notion that clinic backlog is a function of
two simple variables: inflow or the number of consults accepted,
and outflow which is equivalent to the number of patients discharged
or dying. If inflow exceeds outflow, backlog will steadily increase.
Conversely, if outflow outpaces inflow, backlog will decline.
Contrary to popular belief, it is our feeling that care capacity
(the availability of physicians, clinic space, and clinic time)
is not necessarily an important consideration in the solution
of backlog problems, and we usually consider it to be a constant.
As support for this hypothesis, we have significantly decreased
backlog in all of the clinics we have targeted with no increase
in resources allocated.
We have been very discriminating in the acceptance of new consults
and judicious in discharging patients from our subspecialty clinics.
The methods we have found most useful are the strict adherence
to current eligibility criteria and, when appropriate, discharging
patients to primary care or community resources. When contemplating
taking these steps, physicians must ask themselves two basic questions.
First, if I accept a consult and that appointment is set for one
year away, isn't that similar to the patient not receiving an
appointment at all? Second, is it fair to follow all patients
who wish to be seen and see them all at very wide and unacceptable
intervals?
Benefits
By the careful assessment and adjustment of inflow and outflow, one can achieve remarkable and predictable results. We targeted some of our worst clinics in terms of excessive backlog and achieved the following generally gratifying results:
Days to Next Available Appointment
| Audiology | |||||
| ENT | |||||
| Neurosurgery | |||||
| Orthopedics | |||||
| Pulmonary |
The one clearly problematic clinic as of 1994 was Neurosurgery.
In spite of an inflow which was roughly double the outflow, our
Chief of Neurosurgery continued to assign all consult patients
to available clinic slots. Predictably the backlog climbed to
210 days.
We quickly determined that inflow was the major problem. Stressing
this point to our Neurosurgery Chief had no appreciable impact.
We soon discovered that while we were trying to convince him to
deny inappropriate consult requests, he was reaching out to referring
VAs to bolster the number of patients referred, so as to meet
a mandate from our affiliated medical school_to double the number
of operative teaching cases within a one year period. In his mind,
doubling the number of patients evaluated was the logical solution.
To reconcile these conflicting pressures, Neurosurgery agreed
to deal with all consult requests "up front" i.e., using
information and tests already performed; very few patients were
appointed to future clinic slots. In addition, a plan was made
to review available data on many patients with pending appointments
to determine whether they would benefit from surgery. X-rays were
viewed, patients were called on the phone, and further testing
was scheduled; this was usually done without an actual clinic
appointment. Thus, in spite of continued excessive demand, our
effective inflow (consults appointed to clinic slots) was significantly
reduced and backlog appreciably declined.
Contact Person: Mark S. Nelson, MD
Service: Ambulatory Care Service
Facility: Dallas, TX VAMC
Number: (214) 372-7010 or FTS (700) 749-5135
Since the waiting time for new appointments in several of our
subspecialty clinics exceeded the 30 days Customer Service standard,
a utilization review program was initiated. The subspecialty clinics
with the longest waiting times, Arthritis, Neurosurgery, Orthopedics,
and Urology Clinics, were targeted. Appropriateness criteria were
developed by the attending physicians responsible for these clinics
and quality assessment staff; these criteria identify patients
whose care could be safely transferred from the subspecialty clinic
to a primary care provider in the General Medicine Clinic.
The appropriateness criteria are applied to documented patient
information in the medical record or DHCP, and the patient is
either found to be eligible for continued care in the subspecialty
clinic or flagged for possible discharge. If the patient meets
the appropriateness criteria for discharge, a bright pink notification
sheet is left for the provider stating that, according to the
criteria, the patient no longer requires the services of the subspecialty
clinic. If the provider feels that discharge from the subspecialty
clinic is not appropriate, he or she is asked to document the
reason for this decision in a progress note.
Benefits
In the six months this program has been in operation, 2,957 patients
in the Arthritis, Neurosurgery, Orthopedics, and Urology Clinics
were reviewed. Five hundred and seventy three patients were suggested
for discharge from the subspecialty clinic; 398 (69%) had their
care transferred to a primary care provider. The average waiting
time for new appointments in these clinics has decreased from
three months to a month or less. Several other clinics are now
in the process of developing appropriateness criteria and will
be participating in the program.
Contact Person: Karen K. Aalbregtse, BS, CPHQ
Service: Ambulatory Care Service, Quality Assessment
Facility: Ann Arbor, MI VAMC
Number: (313) 761-7189 or FTS (700) 374-7189
I n response to the national timeliness goal established by DVA,
the Louisville VAMC developed a local file written in MUMPS that
calculates patient waiting time in the clinics. Clinics and providers
are selected for review on a monthly basis as part of Ambulatory
Care Service's quality improvement monitors.
At the time the patient is seen, the provider either logs the
patient's name in DHCP or utilizes a light pen that scans the
bar code label located on the back of the medical record. The
computer program logs the time the patient's name was entered
and subtracts that time from their clinic appointment. A daily
report is generated that provides a listing of patients, the time
of their appointment, the time the patient was seen by the provider,
the waiting time per patient, and the average waiting time.
Benefits
The computer program allows us to monitor clinic performance against
the national timeliness goal. Appointment times and work schedules
can then be modified to ensure veterans are receiving timely care.
For the month of May 1995, the average waiting time in the Primary
Care Clinic was 16 minutes.
Contact Person: Marylee Rothschild, MD
Service: Ambulatory Care Service
Facility: Louisville, KY VAMC
Number: (502) 894-6880 or FTS (700) 548-5047
T he following changes were recently made in our primary care
clinics to improve waiting times within a clinic session:
Benefits
Contact Person: Kenneth E. Klotz, Jr., MD
Service: Ambulatory Care Service
Facility: Indianapolis, IN VAMC
Number: (317) 635-7401 or FTS (700) 332-3057
Our Medical Informatics section wrote a local computer program
designed to review our 68 staff physician primary care clinic
sessions and to automatically pull up the first available appointment
slot for a new patient. Previously this had to be done by a clinic
clerk manually reviewing the 68 clinic sessions to locate the
first available appointment. A related computer program, also
developed by Medical Informatics, generates each week an automated
lead time report showing the waiting time for the next available
appointment for each of the 68 physician primary care continuity
clinics, the 34 house staff continuity clinics, and the 12 ambulatory
care block teaching clinics.
Benefits
The first available appointment computer program has enabled us
to:
Contact Person: Kenneth E. Klotz, Jr. MD
Service: Ambulatory Care Service
Facility: Richard L. Roudebush VAMC, Indianapolis, IN
Number: (317) 635-7401 or FTS (700) 332-3057
When we began our primary care program in 1991, we decided to
improve the efficiency of our outpatient clinics. Criteria were
developed for each clinic to provide a basis for prioritizing
care. Emergent, urgent, less urgent, and routine diagnoses were
specified so that appointments could be made in a timely manner
based on clinical need. Inappropriate diagnoses were also listed
so that resources and patient time were not used wastefully. Required
diagnostic testing was also specified with the stipulation that
it was to be completed prior to the appointment, so that patients
would arrive in the clinic prepared for the physician appointment.
To facilitate appropriate referrals and patient preps, this information
has been placed in a Clinic Criteria manual, which is updated
regularly and is available on every ward and clinic; it is also
sent to other VA Medical Centers, especially those that refer
patients to us routinely.
The Urology Clinic had particularly lengthy waiting times and
was targeted for special attention. A veteran could wait several
months to receive an appointment and, on arrival at the clinic,
could wait as long as three hours to see a physician. Because
of these problems, patient satisfaction, as measured in the national
VA survey, was low.
Several interventions were made by the Urology Clinic staff and
the Primary Care Coordinator. First, the medical records of 566
patients were reviewed, and 313 were discharged from the clinic,
as their medical condition did not require care in the Urology
Clinic. The discharged patients were appropriately dispositioned.
After this process was completed, room was available for new profiles,
based on clinic staffing and clinical standards, to be developed.
Failure-to-show rates were built into the profiles to reduce the
need for overbooking, and overbook locks were placed on them to
eliminate uncontrolled overbooking. Finally, a nurse or physician
now screens all consults for clinical appropriateness and timeliness
to promote efficient use of clinic slots and patient time.
Benefits
The following changes have occurred in the Urology Clinic:
The process was so successful in the Urology Clinic that it is
being implemented in all outpatient clinics at our medical center.
Contact Person: Victoria G. Perry, RN, CNA
Service: Primary Care Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 or FTS (700) 383-2615
I n 1994, the Minneapolis VAMC instituted several initiatives
to respond to the need to become more competitive in our changing
health care marketplace. Neurology Service asked its clinics to
study the issues of providing greater access to care and providing
more timely appointments. Four problems were identified:
To address these issues, the Neurology Clinic staff collaborated
with IRM to develop several Fileman programs. One program provides
a listing of the phone numbers of scheduled patients which can
be printed by clinic. (If the patient is an inpatient, the program
lists the ward.) Staff and volunteers use the list to call and
remind the patient four days prior to their appointment. The patient's
address and phone number are verified during the nursing intake
interview.
A second program prints the clinic name and the next five available
appointments. This list is used when a clinic appointment slot
is needed for an urgent or semi-urgent patient.
The third program identifies the patient's past and future neurology
appointments. When an outpatient consult request is received,
the neurology office staff first look through this list to identify
other past or future neurology appointments. This process enables
the office staff to avoid unnecessary or inappropriate visits
and helps them schedule appointments with appropriate clinical
staff.
Benefits
Patients have greater access to the Neurology Clinic and improved
continuity of care. Physicians, nurses, and administrative staff
from the Neurology Clinic use their time more productively.
Contact Person: David A. Rottenberg, MD
Service: Neurology Service
Facility: Minneapolis, MN VAMC
Number: (612) 725-2230 or FTS (700) 780-2230
I t all started with a health fair on Veterans Day in November
1993; the employees had fun and the veterans were enthusiastic.
From this was born the idea of our mobile health fairs. Since
then, there have been from one to four health fairs each month,
and our traveling group has become known as The Roadies.
Several motivated employees share the responsibilities for choosing
the time and place; disseminating publicity; distributing information
packets to interested individuals; and getting the machines, supplies,
and volunteer staff together and to the fair site. Most fairs
have been on a Saturday. Once there, everyone joins in to get
the equipment and information areas set up. Veterans and their
families receive free screening of blood pressure, blood glucose,
cholesterol, and oxygen saturation, and usually there is a dietitian
to do diet counseling.
Some of the health fairs have been done in conjunction with the
openings of our Community Based Clinics, some have been requested,
and others have been done based upon need as determined by analysis
of demographics.
Benefits
Attendance has ranged from 35 to 450 satisfied customers who regularly say how grateful they are that the VAMC would do this for them. The pride and morale of the Roadies build to a new height as they pack their supplies and tired bodies back into the vans or bus for the return trip to Amarillo. Each fair involves interaction of VAMC staff with veterans organizations and local civic groups and promotes a positive image of the Department of Veterans Affairs and the Amarillo VAMC. Access to health care has been provided to veterans who did not know about their benefits or how to get help from the VA; many of these are female veterans. At the first fair 50 new patients, five of whom were female, were gained. At each fair one or more severe hypertensive patients needing immediate intervention are identified and provided with care either at a community facility or at the VA hospital. The Roadies have also promoted a cooperative working relationship across services in the hospital (MAS, Nursing, Dietary, IRM) by working together as a team at the health fairs.
Operation Desert Foot is the Phoenix VAMC's initiative to prevent
lower extremity amputations in our diabetic population. In November
1994, we held our first Operation Desert Foot screening to identify
and begin tracking and treating veterans at high risk for amputation.
We sent out 4,800 announcements, and the 300 appointment slots
were filled in less than three days.
The screening process involved:
Due to the large demand, we now hold the Desert Foot Screening
Clinic once each week to handle the overflow and ongoing referrals.
The screening clinic is also open to non-diabetic patients for
evaluation of their risk status.
Benefits
Early results show a 50% decrease in the rate of amputation within
our patient population. We also anticipate a 70% decrease in the
incidence of vascular and podiatric complications associated with
diabetes due to early identification, education, and intervention.
Since we initiated Operation Desert Foot, our staff and patients
have been increasing their awareness of the conditions that can
lead to amputation and the treatments available to prevent and
treat these conditions. Staff and patient education programs have
been initiated and are ongoing, including a regular staff and
patient newsletter.
Contact Persons: Leslie Wheeler, RN and Alan Langer
Service: Prosthetics Service
Facility: Phoenix, AZ VAMC
Number: (602) 222-6417 or FTS (700) 761-6417
Despite the increasing emphasis being placed on preventive services,
particularly patient education, cancer screening, and adult immunizations,
preventive care is still often not provided. Various strategies
have been tried to increase its use, but few have succeeded. The
literature reveals two strategies that have been successful: transfer
of some preventive care duties to nursing and providing patient-specific
health reminders.
This study, conducted in primary care outpatient clinics at the
Salt Lake City VAMC, examined rates of documentation in patient
charts of 11 widely accepted preventive care interventions, including
patient education (smoking, alcohol habit, diet, exercise, and
seat belt use), screening (blood pressure, colon cancer screening,
and cholesterol measurement), and immunizations (influenza, pneumococcal,
and tetanus-diphtheria vaccines). The rate of documentation of
these interventions was examined at baseline, after transferring
some preventive care responsibilities to clinic nursing staff,
and again after introducing patient-specific health reminders
as a tool for the nurses.
The process of involving the nurses in an effective manner required
two major process changes. First, the Health Maintenance Record
(HMR), a list of preventive services with suggested screening
intervals and areas for data recording, was designed with the
assistance of clinic nurses. This record was printed on heavy
green paper and inserted under the patient problem list on the
left side of the chart. It was moved forward when a new volume
of the medical record was required. Second, standing orders for
immunizations were created to allow the nurses to provide appropriate
immunizations to patients without having to obtain a physician's
order.
The patient-specific health reminders were inserted into each
patient's chart just prior to the appointment. They suggested
preventive care interventions to be performed during the visit.
Benefits
Documentation that preventive care was provided rose dramatically
from a baseline rate of 50% to a rate of 76% with nursing involvement
alone, and to over 97% when nursing involvement and patient-specific
reminders were combined. The rate of documentation of patient
education showed the most dramatic rise, increasing from a baseline
level of 30% to 65% with nursing involvement, and to 95% with
the addition of patient-specific reminders. It was also noted
that attending physicians consistently reviewed the HMR in their
faculty clinics and with residents, especially the guaiac stool
cards and the immunizations. This observation is supported by
documentation in the physician progress notes.
Contact Person: Geraldine Jones, RN
Service: Nursing Service
Facility: Salt Lake City, UT VAMC
Number: (801) 582-1565 Ext 2560 or FTS (700) 539-1565
NOTE: This study was conducted by V.A.V. Foerster, MD for her Masters in Medical Informatics at the University of Utah, Salt Lake City, UT.
T he Infection Control Committee noted that documentation of the
administration of vaccinations was inconsistent. When patients
had more than one volume to their chart, important vaccination
information was not always carried forward. This was particularly
problematic for vaccinations, such as tetanus toxoid or pneumococcal,
that are not needed on an annual basis.
Pharmacy Service worked with IRM and the Infection Control Committee
to develop a DHCP generated vaccination tracking program. All
vaccinations are now entered into the computer generated program;
the date, person who administered the vaccine, manufacturer, and
lot number are recorded. The date of the last vaccination and
the result of any PPD administration are printed on all pharmacy
profiles. Any practitioner can retrieve the more detailed information
through the computer program.
Benefits
Clinical staff have found the program quite handy. The improved
documentation of vaccinations and the easy access to the information
have made it easy to know when vaccinations are needed and have
reduced the number of duplicate vaccinations.
Contact Person: Steven Thomas, R.Ph., MBA
Service: Pharmacy Service
Facility: North Chicago, IL VAMC
Number: (708) 578-3750 or FTS (700) 384-3750
T he Battle Creek VA Medical Center provides services to veterans
within a 200 mile radius. Due to the distances involved, it is
often difficult for veterans to return to the medical center 48
hours after a PPD test is administered. The Ambulatory Care committee
formed an ad hoc group to develop a method to provide our outpatients
with convenient access to PPD screening. The ad hoc group worked
with community health departments to develop a process for patients
who cannot return to the medical center.
All community health departments within our catchment area were
contacted to obtain a listing of the days PPDs are given and read,
the costs for these services, the name of a contact person, and
their willingness to coordinate with our medical center. Index
cards containing the above information were created for quick
reference. Overprinted progress notes with specific instructions
for the patient and community health department were also developed,
and PPD codes were added to the encounter form: one for PPD test
ordered, one for PPD test given, and one for PPD reading (negative
or positive).
During the exit interview, the nurse determines whether the patient
will be using the community health department for either the reading
alone or for both the test and the reading. The patient is provided
with a progress note/information sheet and a self-addressed, postage-paid
envelope for the community health department to mail the progress
note with the PPD reading back to the medical center. The nurse
reviews the information sheet with the patient, filling in appropriate
data, i.e., the community health department's hours, the days
PPDs are given or read, and the name of the contact person. When
the patient is checked out by MAS, the appropriate PPD code is
entered into DHCP.
The progress notes are mailed back to MAS, which enters the appropriate
code for the PPD reading into DHCP. Then, the medical record along
with the progress note is provided to the nurse, who communicates
the PPD results to the appropriate primary care provider.
Tracking is a coordinated effort by MAS and Nursing. On the last
day of each month, MAS runs a list of all patients with incomplete/pending
PPDs. This list is provided to the primary care nurse, who contacts
the patient regarding the status of the PPD screening. MAS is
then notified whether the case is to remain open or is closed.
Benefits
In the four months prior to the initiation of the program in May
1995, 30 PPDs per month were placed and read. In the following
six months, 39 per month were placed and read. The new process
has been primarily of benefit to those outpatients who must travel
a great distance to visit the medical center. Prior to its initiation,
those patients often would not return to the medical center for
a PPD reading. Now they are given the option of utilizing a service
within their community that is coordinated with their primary
care provider. The cost to the patient for this service is minimal,
usually $3.00-$5.00.
Contact Person: Ketan Shah, MD
Service: Ambulatory Care Service
Facility: Battle Creek, MI VAMC
Number: (616) 966-5600 Ext 3851 or FTS (700) 974-3851
A literature review performed when our facility's primary care
program opened identified computer reminders as a useful method
for increasing attention to prevention. Individualized reminders
were beyond the initial capabilities of our informatics system,
but a computer-generated overprint was developed for primary care
notes, reminding clinicians to counsel about diet, exercise, smoking,
and alcohol, and providing a record of previous health maintenance
activities. In addition, we developed and publicized special programs
for smoking cessation and for exercise. Primary care staff also
participated in a faculty development course on prevention.
Benefits
More patients were counseled about exercise in 1993 than in 1992
(41% vs. 35%, p<.05). A higher proportion of primary care patients
who smoked reported being counseled about smoking (21.2% increase;
p<.01). These results were confirmed when we risk adjusted
the patient's health status, and number of visits. The types of
visits for which patients received care also changed, with more
patients receiving check-ups: The proportion of clinic patients
who came in for check-ups was 44% in the post-intervention period
as compared to 35% pre-intervention (p<.001).
Contact Person: Lisa V. Rubenstein, MD, MSPH
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9449 or FTS (700) 966-9449
Sexual impotence and other sexual dysfunctions are among the major
complaints presented to Urology Service by male patients. Urology
Service does not have personnel trained in sexual dysfunction
to evaluate the multiple complexities, both physical and psychological,
that often comprise the complaint of impotence and other sexual
dysfunctions. Patients were routinely referred to Psychology Service
prior to radical procedures such as surgically implanting penile
prostheses. However, for less radical treatments the patients
were most often provided trial and error methods of treatments.
Consequently, many patients were not being helped and were becoming
more confused about their sexual dysfunctioning.
The Urology and Psychology Services at the Little Rock VAMC established
a cooperative referral network to screen all sexual dysfunction
complaints in 1994. A Sexual Dysfunctioning Educational group
is the first course of treatment for the patient and his significant
other. Materials related to male sexual functioning and dysfunctioning
are provided by a staff psychologist certified in sex therapy
in an educational format for about 2 1/2 to 3 hours. Following
this presentation, the patients completes an extensive diagnostic
questionnaire. Patients then are briefly interviewed and are triaged
to the appropriate treatment for their problem: psychological
(sex therapy or psychotherapy), physical (urological or other
medical condition), or both psychological and medical.
Benefits
During the first year of its operation, nearly 100 patients were
seen. This process allows the urology clinic to more quickly see
a large number of patients than could be done on a one-to-one
basis by Urology staff physicians. Patients are responsive to
being seen in a more efficient and effective manner. The process
has also prevented needless and expensive procedures.
Contact Persons: Edward Kleitsch, Ph.D. and Scott MacDiarmid, MD
Service: Psychology and Urology Services
Facility: JLM Memorial VAMC, Little Rock, AR
Number: (501) 660-2071 or FTS (700) 742-3221
Head pain is one of the most frequent presenting complaints in
ambulatory care clinics. Usually, the ambulatory care physician
or treatment team effectively evaluates and treats the patient
without significant complications. However, sometimes the patient's
problem is not readily resolved, and he or she makes repeated
attempts to gain treatment, becoming a "revolving door"
patient. After numerous treatment failures, a referral to Neurology
Service is usually made. By this time patients have often become
tired, disillusioned, and sometimes angry at what they perceive
as mismanagement of their condition.
To address the needs of these patients, the Neurology Service
at the Little Rock VAMC established a Headache Clinic three years
ago and asked Psychology Service to be involved in the screening,
examination, and treatment process. Initially, the Headache Clinic
was conducted one day weekly, with available Neurology physicians
and two staff psychologists seeing all patients individually and
conducting an extensive interview and headache evaluation. Treatment
options included medications and psychological treatments, e.g.,
individual psychotherapies, hypnosis, and biofeedback training.
This initial approach did not resolve the issue of the "revolving
door" patient and opened both consulting services to a flood
of patients. Additionally, patients often complained about being
seen by numerous clinicians, each with their own approach to treatment.
The next step was to assign a single physician and consistent
nursing staff to the Headache Clinic and to institute a multi-disciplinary
course of treatment. Patients are seen initially as new consults
in the Headache Clinic, which meets weekly. After a medical evaluation
including a review of previous treatments, the patient is encouraged
to attend a headache psycho-educational course established by
the two psychologists. This course provides patients with information
about pain in general, head pain in particular, medications used
to treat head pain, and self-regulation methods to prevent and
eliminate head pain. Prior to the first session, each patient
is evaluated with the MMPI-II and the MCMI-2. The course meets
once a month for three consecutive months. Upon completion of
the course, patients are given an opportunity to try hypnosis
or bio-feedback or to attend ongoing headache group therapy to
further control their headaches. Follow-up is provided in the
Headache Clinic, the regular Neurology clinic, or by a private
physician since many of these patients live up to 150 miles from
the hospital.
Benefits
There has been a significant reduction in the number of "revolving
door" patients. Many of the patients who attended the psycho-educational
classes as well as those who received individual bio-feedback
have reported a significant reduction in the frequency and intensity
of head pain. They have also become much more compliant, cooperative,
and receptive to treatment by the Headache Clinic staff; some
have also reported needing fewer medicines and fewer medicine
changes. Finally, there has been a significant reduction in trips
by patients to the Emergency Room with headache complaints.
Contact Persons: Robert B. Doyle, Ph.D. and Sarkis Nazarin, MD
Service: Psychology and Neurology Services
Facility: JLM Memorial VAMC, Little Rock, AK
Number: (501) 660-2071 or FTS (700) 742-2439
For many years, several disciplines provided diabetes education
at our hospital without a coordinated approach. Weekly sessions
were established, but our efforts were fragmented and outcome
data were not collected. As the diabetic population grew and waiting
times became longer, the need to obtain further staff training
to strengthen our program became clear.
Improvement began when we decided to develop a program which could
earn recognition from the American Diabetes Association (ADA).
(Standards for ADA recognition are aligned with Joint Commission
requirements for patient and family education.) A Diabetes Team
involving an endocrinologist, nurse, and dietitian was formed
and the RN and RD received training to become Certified Diabetes
Educators (CDEs). To improve the referral process, nurses on each
floor were identified as Diabetes Resources Nurses and were provided
with inservices by the two CDEs.
A new interdisciplinary Diabetes Education Series was developed
for patients and their families; referred patients are invited
to bring a family member to share in their educational experience.
A series of four classes offered each month covers 15 content
areas specific to diabetes and is designed to enable patients
and their families to constructively change their behavior. Instructors
from Dietary, Nursing, Medicine, Pharmacy, Physical Therapy, Cardiology,
and Psychiatry Services and a patient consumer present information
facilitating goal directed behavior change. Information on basic
physiology, acute and chronic complications of diabetes, treatment
options, adjustment to a chronic illness, healthy food habits,
foot care, taking responsibility for one's own care, and available
supportive resources are included in the curriculum. The Diabetes
Education Series has a broader scope than most patient education
programs: It serves as a stepping stone for diabetes medication
readjustment, and outpatient insulin and glucose monitoring can
be successfully started during the series.
Prior to attending the Diabetes Education Series, patients are
assessed for educational needs and asked to develop behavioral
goals for themselves. After completing the four classes, graduate
patients are given a three month follow-up appointment to assess
their success in changing their behavior to meet their personal
goals.
The nutrition class provides hands-on meal planning, utilizing
a match game that helps patients learn to create a balanced meal.
By making choices from the various food groups, they learn to
identify carbohydrates, proteins, and fats while preparing their
own meal. A yard sale game involves patients in choosing items
to use in life-like scenarios in daily diabetes management and
in emergencies. It is a useful indicator of patient retention
and comprehension and is a useful replacement for the traditional
pre- and post-tests. Because the game brings humor to the learning
process, it is popular among patients.
Benefits
Contact Person: Nancy McCullough, RN
Service: Nursing Service
Facility: White River Junction, VT VAMC
Number: (802) 295-9363 or FTS (700) 829-5726
Traditionally, patient education at our clinic has been provided
by nursing during the patient's exit interview at the end of his
visit. While evaluating performance improvement data two years
ago, the nursing staff concluded that the education being provided
at this time was often not effective. The obstacles to effective
patient education were:
The nursing staff concluded that providing education during the
intake assessment would eliminate some of these obstacles to effective
patient education. By starting the visit with patient education,
the nurse would have more time to assess the patient's readiness
for learning and to provide the necessary education and preventive
health information required to make sound health care decisions.
Exit interviews could be confined to changes in the treatment
plan and explaining preps for diagnostic tests, thus avoiding
information overload.
Benefits
Dividing the education process into two parts has improved patient
compliance and the identification of health risks. Referrals by
nursing for health risk interventions, such as the smoking cessation
clinic and nutrition classes, have doubled. Patient satisfaction
and feedback both indicate that this new approach has been well
received by the clinic's clients. Finally, nursing staff morale
has improved because of the patient's positive feedback and their
own sense of doing a better job of teaching.
Contact Person: Janice Hess, ARNP, MSN
Service: Nursing Service
Facility: William V. Chappell, Jr. VAOPC, Daytona Beach, FL (Gainesville VAMC)
Number: (904) 274-4600 or FTS (700) 848-9144
Alcoholics with severe medical illnesses are known to consume
a disproportion- ate amount of health care resources. These patients
report to urgent care areas frequently and may require multiple
hospitalizations for alcohol-related medical complications. Medical
staff, however, are often inadequately trained to screen, identify,
and effect change in patients who drink hazardously. In addition,
traditional chemical dependency programs do not have adequate
resources to meet the wide range of medical needs of this population.
In April 1987 the Health Improvement Program/Alcohol Related Diseases
(HIP/ARD) Clinic was established at the Minneapolis VAMC to provide
primary outpatient medical services and long-term case management
for these patients. The clinic provides preventive health care,
routine treatment of medical problems, and education to prevent
relapses. If there is a need to hospitalize a patient, the HIP/ARD
team continues to work with the patient while they are in the
hospital and helps with discharge planning. The treatment team
is interdisciplinary and includes a family physician, two nurse
practitioners, an RN educator, a social worker, a psychologist,
and a part-time psychiatric consultant. The most frequent diagnoses
treated include alcoholic liver disease, pancreatitis, gastrointestinal
bleeding from esophageal varices or gastritis, alcoholic cardiomyopathy,
alcoholic peripheral neuropathy, and chronic cerebellar degeneration/ataxia
secondary to alcohol.
The team currently is providing long-term management for 150 patients.
Care is often intensive at the outset and then becomes less intensive
as the patient stabilizes and becomes known to the clinic staff.
Patients are typically discharged after two years of sobriety
or stability; in FY 1994, the HIP/ARD Team discharged approximately
30 patients into the General Outpatient Medicine Clinics at this
hospital.
Benefits
Based on a quasi-experimental study published in the May 1995
edition of The Journal of Studies on Alcohol, it appears that
the HIP/ARD clinic may be reducing levels of morbidity and mortality
in this population. A five year HSR&D grant is currently underway
to study the efficacy of the HIP/ARD clinic experimentally.
Contact Person: Douglas H. Olson, Ph.D.
Service: Psychology Service (HIP/ARD Clinics), Addictive Disorders Section
Facility: Minneapolis, MN VAMC
Number: (612) 725-2228 or FTS (700) 780-2228
In February 1991, the Admission Intervention Team (AIT), an interdisciplinary
team consisting of two .25 psychiatrists, one .75 nurse, one .75
psychologist, and one full-time social worker, was formed to work
with patients who were high users of inpatient psychiatric care.
Any veteran with three admissions to general psychiatry within
12 months is referred for follow-up by the AIT. At present, 77%
of veterans followed by AIT are dually diagnosed. The only exclusion
criterion is the sole diagnosis of substance abuse.
The AIT provides intensive follow-up and case management. The
team works closely together to individualize treatment plans and
to develop individualized interventions and strategies to meet
the veteran's needs, whenever possible on an outpatient basis.
For example, we have taken an aggressive approach to ensuring
medication compliance. The use of court-ordered compliance, known
as Mandatory Outpatient Treatment (MOT) in Tennessee, is one way
we have done this. While this process involves recertification
of need every six months and filing affidavits and making court
appearance when the patient is non-compliant, it has proven very
effective for the approximately 15% of AIT patients who are on
MOT status. Similarly, if our patients fails to report for a neuroleptic
injection, we pursue them. We telephone them, their family, or
their court-appointed guardian to encourage them to come in. If
there is some compelling reason that a patient cannot come to
the hospital, such as debility or extreme paranoia, we go to his
or her home or send a home health agency there to administer the
injection. We have on occasion had the patient's guardian mail
a veteran's weekly spending money to the medical center to ensure
that he or she comes in to the clinic.
We have also taken an assertive approach to the management of
our veterans' personal resources. We have initiated competency
ratings through the VA Regional Offices in pursuit of fiduciary
or guardian appointments. We have also initiated payee relationships
with Family Services of Memphis, an agency that serves as payee
for people who do not have a willing family member or friend.
Once a guardian or payee is established, we work aggressively
with him or her to insure that the veteran's basic needs of housing
and food are met and, as mentioned above, to encourage treatment
compliance. We negotiated with Fiscal and Medical Administration
Services to allow some of our outpatients to maintain active Patient
Funds accounts. (Previously, these were restricted to inpatients.)
This allows some of our patients who come to the VAMC regularly
for treatment to withdraw money from their account each day for
transportation and meals. The funds are deposited by the guardian
who specifies the frequency and amount of permissible withdrawals.
Since its inception, the AIT has emphasized continuity of care.
With the same small group of providers seeing the same patients
consistently over time, we become quite familiar with the individual
patients. The veteran also gets to know the providers well, and
this often leads to greater trust than the patient has previously
experienced. The consistency also reduces the opportunity for
manipulation and splitting of staff.
The AIT is quite flexible about seeing patients on an unscheduled
or urgent basis. We are also able to spend considerable time with
a patient in crisis. The AIT staff, operating as a team, is much
more willing to risk not admitting a veteran than most outpatient
psychiatry staff who function independently. The AIT operates
as a true interdisciplinary team, as differentiated from a multi-disciplinary
team: The team members willingly take on problems and tasks without
strict regard to professional discipline, except when necessitated
by the constraints of licensure.
Benefits
The number of psychiatric admissions for patients followed by
AIT was compared to the number prior to the initiation of the
program. There were reductions of 62% in the first year of the
program, 72% in the second year, and 70% in the third year. Assuming
that the number of hospitalizations would have remained constant
if AIT had not been implemented, the cost savings to the medical
center were calculated to be approximately $550,000 for the first
year, $700,000 for the second year, and $800,000 for the third
year, for a total savings of over $2,000,000.
Contact Person: Lynda Penny, LCSW
Service: Psychiatry
Facility: Memphis TN VAMC
Number: (901) 523-8990, ex 5321 or FTS (700) 222-5321
Traditionally, psychiatric referrals at our facility came unannounced
from Ambulatory Care and had to be seen as "drop-ins."
This process was very disruptive to the operation of the Mental
Health Clinic, and patients frequently became more agitated while
waiting to be "worked-in."
A structured triage system for referrals was developed to address
these concerns. Ambulatory Care staff were asked to categorize
referrals as urgent or non-urgent; urgent patients were those
with suicidal or homicidal ideation, attempts, or threats, or
who were actively psychotic or exhibiting uncontrolled behavior.
The triage coordinator, who is accessible via pager, is contacted
regarding both urgent and non-urgent referrals. All urgent referrals
are seen immediately by the triage coordinator and a staff psychiatrist.
The veteran can be seen either in the Outpatient Psychiatry area
or in the Ambulatory Care setting. Non-urgent referrals are scheduled
into a newly established clinic that meets daily for two hours
to evaluate and screen these patients.
Benefits
The structured triage system has resulted in:
Contact Person: Tempie M. Evans
Service: Nursing Service
Facility: Columbia, SC VAMC
Number: (803) 776-4000 Ext 6167 or FTS (700) 677-6823
Patients with both schizophrenia and substance use disorders are
difficult to treat as outpatients. They are often non-compliant
with psychiatric treatment, are frequent users of inpatient psychiatry
services, are usually too psychologically frail for traditional
substance abuse programs, and are vulnerable in the community
when using alcohol or drugs. To meet their special needs, Outpatient
Psychiatry (OP) and Dual Diagnosis Program staff developed a special
outpatient treatment program for these patients. During two 4-hour
sessions each week, they attend a combination of groups focused
on psycho-social education, problem solving, social resources,
relapse prevention, therapeutic recreation, and physical exercise.
They are monitored with urine toxicology screens. Many patients
who were never before committed to abstinence have committed and
achieved it, while others have significantly reduced alcohol and
drug use.
Benefits
Of the 102 patients who participated during the first nine months
of the program, 50% remain enrolled in outpatient treatment and
report increased self-esteem, coping skills, and stability. Of
the 50 patients currently in the program, 20% have documented
sustained abstinence for a variable but meaningful period of time.
Primary care providers report increased medication compliance
and more stable functioning. Patients report benefiting from the
structure of the program and gaining social support from interacting
with other patients with similar problems, as well as increased
skills in recognizing signs of relapse and managing psychiatric
symptoms. As a result of their more regular outpatient contact,
they recognize their symptoms and report problems sooner to avoid
relapse and recidivism.
Contact Person: Carolyn Cassin, Psy.D.
Service: Psychiatry Service
Facility: Westside VAMC, Chicago, IL
Number: (312) 455-5841 or FTS (312) 455-5841
T he Bipolar Disorder Program (BDP) is a high intensity ambulatory
treatment program based on collaboration between nurses and physicians
and between caregivers and patients. The program utilizes nurse
clinical specialists as primary care providers with physician
back-up. The population served is veterans with bipolar or schizoaffective
disorders. Bipolar disorder is a chronic, severe mental illness
which affects 1% of the population; it leads to substantial social
and occupational functional impairments, but its victims have
considerable rehabilitative potential. The BDP's only medical
or psychiatric exclusion criteria is severe dementia, which would
impair the patient's collaborative role.
The BDP emphases intensive medical management supplemented by
ongoing psychoeducation to increase patient participation in health
care assessment and decision making. Easy patient access to the
primary caregiver and patient decision making are the key principles
of the program. In addition to the high intensity individual treatment
program, patients have the option of participating in therapy
groups specifically developed for patients with bipolar disorders.
The groups emphasize training in illness management and facilitation
of the achievement of life goals. They are manual driven and have
cognitive-behavioral and interpersonal theoretical underpinnings.
Benefits
Data were collected on the first 76 patients who completed six
months of the program. Compared to baseline, patients at six months
showed highly significant increases in satisfaction with care
and intensity of medication treatment and a trend toward decreased
exposure to neuroleptics. There were significant decreases in
the use of emergency medicine and psychiatry services, and in
the frequency of psychiatric hospitalization compared to the prior
year. As expected, the number of ambulatory mental health clinic
appointments increased. Nevertheless, annualized expenditures
for the cohort fell to approximately 53% of the prior year due
to the decreased use of more costly services.
Contact Person: Mark S. Bauer, MD
Service: Psychiatry Service
Facility: Providence, RI VAMC
Number: (401) 457-3057 or FTS (700) 838-3057
We created a Primary Psychiatric Care Team (PPCT) in August 1995
to provide primary care for psychiatric patients. The PPCT consists
of an M.D. (boarded in both Psychiatry and Internal Medicine)
a nurse practitioner, an RN, an L.P.N., and a social worker. All
patients receiving outpatient psychiatric care in the Mental Hygiene
Clinic (MHC) are eligible. The PPCT works with MHC psychiatrists
to select patients not already enrolled in another primary care
team. The MHC psychiatrist remains the attending of record and
is encouraged to become as involved in the patient's primary care
as he or she wishes.
A new patient undergoes a comprehensive, multi-disciplinary work-up
including computerized psychometrics, nursing evaluation, history
and physical, and social work evaluation. At its next weekly meeting,
the team completes a total biopsychosocial formulation. The patient
is then followed by each member of the team for specific treatment.
Nursing provides education, health screening, and immunizations.
The nurse practitioner or physician provides medical follow-up
and walk-in medical care, and the social worker addresses social
needs. The team physician, working with the MHC psychiatrist,
provides psychiatric care and coordinates the team's efforts.
Benefits
This program combines the advantages of primary care and specialized
psychiatric care for a patient population with unique needs. The
number of patients cared for by the program has grown to about
150 patients during its first three months of operation. A computerized
tracking system for medical outcome variables is currently being
developed.
We understand that the union of psychiatry and primary care will
create unique clinical challenges, but believe that the two are
compatible and represent a future direction of health care. Extrapolation
of the model to other facilities should not require the presence
of staff boarded in Internal Medicine and Psychiatry. For example,
other programs have reported the successful use of nurse practitioners
with psychiatric experience who were supervised by an internist
familiar with psychiatric issues.
Contact Person: Bradford Felker, MD
Service: Psychiatry Service
Facility: Salem, VA VAMC
Number: (703) 982-2463 Ext. 2515 or FTS (700) 937-2515
T he Chillicothe VAMC wished to increase the degree of intensive
management for "High Risk" patients enrolled in the
Mental Hygiene Clinic (MHC). This group includes patients who
have histories of being dangerous to self or others, those who
decompensate due to non-compliance with treatment, those who lack
adequate external support systems, and those with poor anger control
and certain personality disorders. We established protocols for
case management when these patients require rapid interventions.
A network was established for each patient through communications
with family members, relevant others, and community agencies to
allow for appropriate intervention. If a "High Risk"
patient misses a scheduled appointment, does not request medication
refills on time, or does not keep other commitments essential
to maintaining psychiatric stability, the Chief of Nursing Service
contacts the appropriate network resource to mobilize support
for the patient to perform the needed activity. Stat appointments
are also employed. Regular case management reviews of these patients
are conducted by the interdisciplinary MHC team, and the importance
of following up all incidents of concern and completing interventions
is regularly reinforced.
Benefits
The number of untoward incidents involving high risk psychiatric
patients has been sharply reduced, and patients who are known
to rapidly and regularly decompensate have remained much more
stable. The degree of administrative concern over the actions
of high risk psychiatric patient in the community has also notably
decreased.
Contact Person: Carol Wermuth, MSN, MBA, RN
Service: Nursing Service
Facility: Chillicothe, OH, VAMC
Number: (614) 773-1141 Ext 7365 or FTS ( 700) 975-7365
T he Minneapolis VAMC had highly inefficient and uncoordinated
procedures for admitting patients into its inpatient and outpatient
chemical dependency and psychiatry programs. Staff as well as
patients were confused about which program was most appropriate
and would send consults to four or five programs hoping that one
would be appropriate. As a result, there was much duplication
of consults and unnecessary assessments and reassessments for
program placement.
In 1993, the multidisciplinary Assessment, Crisis, and Consultation
(ACC) team was established and given responsibility for all initial
evaluations for psychiatry and chemical dependency services. The
ACC team, consisting of clinical nurse specialists, psychiatrists,
a social worker, and a psychologist, determines whether the patient's
initial need is for hospitalization, crisis management, or short
term outpatient therapy and to which treatment team the patient
will be assigned. In addition, the ACC Team monitors all admissions,
inter-hospital and intra-hospital transfers, and prearranged admissions.
To further reduce the number of assessments by program staff,
a comprehensive database was developed for use by all psychiatry
and chemical dependency services. Initial evaluations includes
the history of psychiatric illness, chemical dependency, and medical
status. This comprehensive evaluation allows for better determination
of a patient's treatment needs early in the treatment process.
Phase II of this system will include rating scales which can be
optiscanned. They will be used to generate a narrative database,
which can be used in any program as an initial database and treatment
plan.
Benefits
The use of the ACC Team has improved treatment planning and service
utilization. Consequently, we have been able to eliminate waiting
lists for inpatients beds and have reduced our length of stay
to community standards. We have also eliminated duplication of
assessments and facilitated transfers and patient care planning
by using the same database across psychiatric and chemical dependency
services.
Contact Person: Mary Olson RN, MSN, CS
Service: Psychiatry Service
Facility: Minneapolis, MN VAMC
Number: (612) 725-2000 Ext. 2979 or FTS (700) 780-2979
Prior to this initiative, psychological consultation to primary
care involved the physician writing a consultation request and
forwarding it through interdepartmental mail; the psychologist
would contact the patient to schedule an appointment and, after
seeing the patient, complete a consultation report which would
be placed in the patient's medical record. This process typically
resulted in patients making an additional trip to the hospital,
requiring a delay of at least two to three days before they were
seen by the psychologist, and then delaying feedback to the referring
physician for an additional day or more.
To create a more efficient system, psychology staff were assigned
to cover the various half-day primary care clinics which comprise
the Faculty Medical Clinic and the General Medical Clinic. Psychologists
often remain in the clinic area throughout the half-day schedule;
if there are times that they cannot be physically present in the
clinic, they can always be reached by pager. A dedicated pager
number is used for this purpose to eliminate any confusion over
how to reach the psychologist. Psychology staff are thus available
to provide immediate consultation to medical staff and to conduct
brief evaluations or provide interventions with patients at the
time of their clinic visits. The emphasis is on providing immediate
service rather than requiring a consult to be sent and a follow-up
appointment scheduled. Typical issues assessed include the psychological
impact of the illness or injury, psychological factors involved
in compliance, screening for possible psychiatric or substance
abuse problems, and possible psychosocial factors involved in
treatment-seeking. These assessments may lead to specific treatment
recommendations, or, in some cases, recommendations for more extensive
evaluations. Psychological treatment offered at the time of the
original clinic visit include crisis intervention and supportive
counseling of the patient or their family.
Benefits
The major benefit has been improved efficiency of service, resulting
in greater convenience to patients and more timely feedback to
staff. A process that used to require several days is now typically
completed in an hour or less. In addition, the presence of psychologists
in the clinic has led to an increase utilization of psychological
services, resulting in improved patient care.
Contact Person: Robert C. Green, Ph.D.
Service: Psychology Service
Facility: Clement J. Zablocki VAMC, Milwaukee, WI
Number: (414) 384-2000 Ext. 1650 or FTS (700) 383-1650
Long-term prophylactic agents for ulcers such as H2 antagonist
agents, omeprazole, and carafate are widely used in the VA to
treat ulcer disease, accounting for more than $85 million dollars
in expenditures in the VA for 1994. The approaches used in the
last five to ten years at our hospital to control the cost of
these agents met with varying success. Most of these strategies
centered around placing patients on the least expensive agent
and restricting the duration of therapy. However, many patients
lacked an assigned primary care provider and were seen by multiple
general medicine physicians as well as specialists. These physicians
were often reluctant to take a patient off of a prophylactic agent,
because of their uncertainty about why the patient was given the
medication and their inability to assure adequate follow-up.
During this same period, data from numerous studies clearly pointed
to the relationship between H. pylori and the development and
recurrence of ulcer disease. This research demonstrated that eradication
of H. pylori decreases recurrence rates of ulcers. In response
to these findings, the NIH Consensus statement in 1994 concluded
that patients with ulcers should be evaluated and, when appropriate,
treated for H. pylori.
The need to try a new approach to cost containment and the consensus
regarding the role of H. pylori on ulcer formation led our facility
to establish a H. pylori clinic. Patients receiving agents for
ulcer prophylaxis are scheduled into the clinic, which is managed
by a pharmacist and overseen by the Chief of Gastroenterology.
Patients are seen in this clinic in addition to their primary
care clinic and are referred back to their primary care provider
at the conclusion of their testing or therapy.
Patients found to be H. pylori positive are maintained on acid
suppressive agents and treated with one of several antibiotic
regimens, depending on their allergies, potential drug interactions,
and previous antibiotic experience. The drug regimens include
combinations of the following agents: omeprazole, clarithromycin,
amoxicillin, tetracycline, metronidazole, and occasionally bismuth.
Patients who are found to be positive and treated are seen again
at the end of their H. pylori treatment course. Patients who have
no documented history of ulcers are not tested for the presence
of H. pylori and are taken off their chronic medications and followed
over time.
Benefits
The most expensive antibiotic regimens cost under $50.00, a small
amount compared to the annual savings achieved by not treating
patients with long-term prophylactic agents. Annual cost savings
for a patient currently receiving ranitidine are approximately
$180-$200 per patient year. At our hospital we identified approximately
500 patients who were receiving these agents solely to prevent
recurrence of their ulcers. Cost savings, if all these patients
are successfully treated, would amount to approximately $100,000
annually.
Contact Person: Anthony P. Morreale, Pharm.D., MBA, BCPS
Service: Pharmacy Service
Facility: San Diego, CA VAMC
Number: (619) 552-8585 or FTS (700) 897-3206
Prior to initiating an express line, we processed prescriptions
on a first-come, first-serve basis. Veterans turned their prescriptions
in at our outpatient pharmacy turn-in window; we filled the prescriptions
and placed the veterans' names on a monitor when their medications
were ready; the veterans then came to our outpatient pick-up window
and received their medications. Most veterans waited an average
of 45 minutes to obtain their medications, no matter how many
prescriptions they turned in for filling. Many of our patients,
especially those with one to two prescriptions, found it difficult
to understand why it took an average of 45 minutes for us to fill
their medications.
After reviewing several possibilities, we decided to add an outpatient
express line similar to those found in grocery stores for customers
purchasing a small number of items. We changed a small patient
counseling room close to our existing outpatient pick-up windows
into our express line. We initially urged veterans with one or
two prescriptions to use the express line, guaranteeing them that
their prescriptions would be filled within ten to 15 minutes.
We asked the veterans to wait in the express line while we filled
their prescriptions, eliminating the need to see them twice. These
changes resulted in an average waiting time of less than 15 minutes
with no increase in staffing.
We recently made several modifications to our express line. We
now give veterans presenting prescriptions at our outpatient pharmacy
three options:
We no longer place any restrictions on the number of prescriptions
processed in our express lines. Also, pharmacists now counsel
patients as they input prescriptions. Our pharmacy technicians
fill these orders, and pharmacists check them before the patient
receives the medication. We split orders for more than five prescriptions
between several technicians so they do not take any longer than
small ones.
Benefits
Contact Person: James C. Gatewood, Jr., R.Ph.
Service: Pharmacy Service
Facility: Atlanta, GA VAMC
Number: (404) 728-7642 or FTS (700) 248-7642
Prior to 1994, the outpatient pharmacy at the Seattle VAMC followed
the traditional model, designing its work flow around the filling
of prescriptions. Patients were dissatisfied with the long waiting
times for prescriptions, poor accessibility to pharmacists, and
the inability of the system to handle their individual needs.
Pharmacy staff came to the realization that the focus of our tasks
had to become the patient.
We decided that pharmacists were needed in the clinics where veterans
were being treated and prescriptions were being written. Placing
them in the clinics would enable them to function more fully as
members of the health care team and participate in medication-related
decision making. It would also make pharmacy services more accessible
to both patients and providers, facilitating problem solving and
eliminating many of the barriers to quality care which existed
with the current system.
In January 1994, one pharmacist was placed full-time in the General
Internal Medicine Clinic. Prescription entry, patient counseling,
medication profile reviews, answering pharmacy-related telephone
calls, and providing drug information to medical staff and patients
were routine functions of the clinic pharmacist. As time went
on, her role expanded: She reviewed medication profiles prior
to clinic appointments to screen for drug-related problems, made
follow-up calls to patients when needed, routed problem or non-refillable
prescriptions to the appropriate providers, and took care of all
drop-in patients with medication inquiries. Because of the enthusiastic
response to these new functions from patients and providers, a
second pharmacist was moved into the clinic in June 1994.
After the success of the internal medicine program, we looked
for another clinic which would benefit from direct pharmacist
intervention. Our Patient Evaluation Center (PEC), or "Walk-in
Clinic" seemed the best candidate, and a pharmacist was moved
there in the spring of 1995. In addition to counseling all patients
seen in the PEC and inputting their prescriptions, she has been
assigned responsibility for the refill clinic and given prescriptive
authority for refills on all medications except for controlled
substances. The PEC pharmacist is also the primary pharmacy representative
involved in our medical center's Telephone Care Program and answers
all pharmacy-related telephone calls coming in on that line.
Benefits
As pharmacists became visible in the clinic, patients came to
identify and trust "their pharmacist" and were assured
that their individual medication needs were important and would
be addressed. Rather than feeling that they and their questions
were an interruption in the system, veterans began to sense that
they had become the center of the process. This was reflected
in the feedback given to us in a satisfaction survey, distributed
over a two week period to patients with scheduled appointments.
The satisfaction of patients who saw the pharmacist in clinic
was compared to the satisfaction of those who talked only to a
pharmacist in the outpatient pharmacy. Patients who spoke to a
clinic pharmacist rated pharmacy services higher in all ten areas
specified on the questionnaire, including attentiveness by the
pharmacist; being provided instructions regarding how to take
medications, the purpose and possible side effects of medications,
and whom to call with questions; waiting time for prescriptions;
and overall service. All differences were statistically significant
with the typical difference about .5 on a five point scale.
Feedback from other clinical staff has been continuous and overwhelmingly
positive. Pharmacy services in the clinics eliminated a large
portion of their telephone calls, and pharmacists were readily
available to answer their questions and counsel patients.
Pharmacy Service was also able to decrease re-work by being present
in the clinic. Much of the pharmacy's time is devoted to problems
which could have been prevented if things were done correctly
the first time. For example, we were aware that many of the clinic
prescriptions we filled were never being picked up by veterans.
Patients who spoke directly to a pharmacist in the clinic were
less likely to leave their medication behind.
Because the clinic pharmacists were able to take most of the their
distributive functions with them, pharmacy was able to accomplish
these improvements with no net increase in staffing. Plans are
in place to further decentralize staff to the remaining clinics
in the medical center in the near future.
Contact Person: Pamela Seymour, R.Ph.; Shelley Saiki, Pharm.D.; and
Kristin Petke, R.Ph.
Service: Pharmacy Service
Facility: VA Puget Sound Health Care System, Seattle, WA
Number: (206) 764-2230 or FTS 700-396-2230
Prior to 1993, many concerned staff believed that most patients
receiving anticoagulation (warfarin) therapy on an outpatient
basis were not receiving adequate monitoring to ensure therapeutic
dosing. Cardiology had a nurse-run PT clinic, but no other clinics
had any organized follow-up for patients receiving anticoagulation
therapy. Several key clinical staff met in 1993 and developed
a flow sheet to help follow the warfarin history of each patient.
PT clinics were started in the General Medicine Clinic and the
Primary Care Clinic. The monitoring process improved but still
had flaws, and many patients continued to be lost to appropriate
follow-up for their anticoagulation therapy.
The involved staff met again and agreed that all patients receiving
anticoagulation therapy on an outpatient basis could be best served
by being followed in a single clinic managed by a clinical pharmacist.
An Anticoagulation Clinic Protocol was developed by the involved
parties. The Pharmacy & Therapeutics Committee endorsed the
proposal and recommended that a pharmacist managed Anticoagulation
Clinic be established, with oversight from the ACOS/Ambulatory
Care and with appropriate consultation from physicians in the
outpatient clinics. The Anticoagulation Clinic began receiving
its first patients on October 1, 1993. Pharmacy Service has developed
a mechanism to ensure that every patient receiving anticoagulation
therapy in the medical center is entered into the clinic.
Benefits
The major benefit from this program is a reduction of the number
of admissions related to bleeding among patients receiving anticoagulation
therapy. In the baseline fiscal year of 1992, 8.65% of patients
receiving anticoagulation therapy had admissions related to bleeding.
At the end of FY 1994, the admission rate had fallen to 3.22%
of patients receiving anticoagulation therapy. During FY 1994,
pharmacists were able to handle 99.7% of 2,578 Anticoagulation
Clinic visits without referral to a physician. This allowed the
physician time that would have been devoted to these visits to
be utilized elsewhere.
Contact Person: John D. Burke, R.Ph.
Service: Pharmacy Service
Facility: Louisville, KY VAMC
Number: (502) 894-6178 or FTS (700) 548-5890
When appointments are canceled because of a primary care physician's
upcoming leave, the next available appointment is sometimes not
consistent with the amount of medication remaining to the patient.
A multidisciplinary team was established to address this problem
and developed the following procedures. The physician's leave
schedule is given to MAS and patients are rescheduled. However,
letters notifying the patients of the appointment change are not
sent at this time. Instead, a list of the appointment changes
made that day is given to Pharmacy Service, which determines whether
each patient has an adequate supply of medication to last until
their new appointment date. For patients who will run out, an
action profile is provided to the primary care physician, who
either extends the prescription or requests an earlier appointment
for the patient. If the prescription is extended, the amount of
medication is calculated to go one week beyond the new appointment
date. MAS then sends a letter to the patient stating the new appointment
time and telling him or her that they can receive a refill when
they need it.
When the action profiles are returned to the pharmacy, the prescriptions
are suspended to one day after the new appointment date. If the
patient does not show up for the appointment, the primary care
physician is asked if the medication should still be provided.
Depending on the answer, the pharmacists either mails the medication
to the patient or cancels the prescription.
Benefits
The primary benefit is that patients see their primary care physician,
rather than coming to the clinic for an unscheduled visit to obtain
a medication refill. Patients also appreciate knowing that they
do not have to be concerned about their medications when their
appointment is changed. There has also been a reduction in the
number of patients coming to the open pharmacy, which has compensated
for the increased responsibilities Pharmacy Service has undertaken
in this program.
Contact Person: Vivian S. Kalberer, R.Ph.
Service: Pharmacy Service
Facility: Butler, PA VAMC
Number: (412) 477-5032 or FTS (700) 721-5032
To improve efficiency and reduce processing time in the pharmacy,
our hospital implemented an Automated Pharmacy Information System
in May 1995. This system, which is produced by MUMPS AudioFax,
enables patients to order prescription refills and check their
prescription status, future appointments in all clinics, and pharmacy
co-pay status over the telephone.
Benefits
There has been a very positive response from patients regarding
the Automated Information System even though it has only been
in operation a short time. More and more patients are using this
system because it saves them both time and money. Processing time
has been reduced in the pharmacy since fewer prescription renewal
requests are being received through the mail. The Automated Information
System has improved pharmacy efficiency, while making pharmacy
services more readily accessible to patients.
Contact Person: Michael S. Rybicki
Service: Medical Administration Service
Facility: Wilmington, DE VAMC & Regional Office Center
Number: (302) 633-5290 or FTS (700) 487-5290
Medications ordered through the Mental Hygiene Outpatient Clinic
at Coatesville VAMC are authorized for refill by a physician or
an appropriately credentialed RN. The previous process required
the clinician to sign and date the medication profile sheet, which
the patient would then take to the pharmacy for processing. The
waiting time would often be 45 minutes to one hour.
A system of authorization by electronic signature has dramatically
decreased the waiting time for the processing of refills. While
the patient is still in the office, the clinician "signs"
the profile by selecting each medication to be refilled on the
computer. The medication label is immediately printed in the pharmacy,
informing the pharmacists of the authorized refill. The refill
process thus begins while the patient is still in the clinician's
office. The system is programmed to not allow a refill authorization
if insufficient time has elapsed since the last refill or if there
are no available refills on the prescription. Previously, this
had to be determined by visually scanning the profile sheet.
Benefits
Patients now report the waiting time to be only minutes, and frequently
the prescription is waiting for them when they arrive at the pharmacy.
Patients who had previously left the hospital and returned later
in the day or the following day to pick up their prescriptions
no longer need to do this. There has also been a change noted
in the urgency previously experienced by some patients to quickly
complete their appointment so they could turn in their refill
slips.
Contact Person: Carolyn Zelek, RN
Service: Ambulatory Care Service
Facility: Coatesville, PA VAMC
Number: (610) 384-7711 or FTS (700) 695-5216
An outpatient pharmacist discovered the need for special medication
labels for visually impaired patient through her participation
on the Visually Impaired Services Team (VIST) at this medical
center. Many visually impaired patients are unable to comply with
medication regimens because they cannot read their medication
labels and have no one to assist them. We developed two special
features that are available to our visually impaired veterans.
"Dots" can be placed on the bottles for visual and tactile
purposes; these are colorful, raised circles, bars, or squares
that stick to bottles to denote the number of doses per day. Large
print labels can be also be made using word processing software
such as Word and WordPerfect. Currently, we have about 20 patients
using our large print labels. All glaucoma eye drops also have
large print labels placed over the regular label to assist patients
receiving these medications. We are using pre-printed labels for
metipranolol, pilocarpine, betaxolol, and apraclonidine.
Visually impaired patients are identified in DHCP so that these
services are consistently provided to them. The Eye Clinic also
notifies us if there are new patients who should have special
labels.
Benefits
Visually impaired patients are better able to comply with medication
regimens without assistance, thus improving compliance.
Contact Person: Susan McCoy, R.Ph.
Service: Pharmacy Service
Facility: McGuire VAMC, Richmond, VA
Number: (804) 230-1319 or FTS (700) 698-2315
Pharmacy Service receives an average of 150 telephone calls per
day, many of which involve questions from patients and staff.
In the past, no one was designated to answer phone calls, and
the telephone would often ring many times before anyone answered
it. Questions were answered by a variety of staff, and the answers
were often quite variable. If one of the pharmacy technicians
answered the phone, frequently they would need to find a pharmacist
to answer the questions.
A telephone pharmacist position was established to address these
concerns and to prevent interruptions for the rest of the outpatient
pharmacy staff. The pharmacist answers all telephone calls to
the outpatient pharmacy and inputs mail-out prescriptions between
calls.
To help the telephone pharmacist respond accurately and quickly
to inquiries, a telephone question log book was compiled. The
most frequently asked questions were identified, and several staff
collaborated to perform the necessary research and write accurate
and appropriate answers.
Benefits
Our ability to quickly provide consistent and accurate answers
to commonly asked questions is greatly appreciated by veterans
and clinical staff. The number of documented medication errors
has also been reduced by 52% since implementation of the telephone
pharmacist position. The entire reduction cannot be attributed
to the establishment of this position, since a pharmacy renovation
project completed during the same period improved work flow and
doubled the lighting in the area. But we believe the establishment
of the telephone pharmacist position also contributed to the reduction
in medication errors.
Contact Person: Richard Rooney, Pharm.D.
Service: Pharmacy Service
Facility: Lakeside VAMC, Chicago, IL
Number: (312) 640-2240 or FTS (700) 384-8000
To reduce patient waiting time for processing renewal and refill
prescriptions that the patient will not need for at least five
days, we have placed a priority prescription mail drop box outside
the outpatient pharmacy. This service allows patients who will
be continuing current medication therapy, but are not in immediate
need of medications, to drop off prescriptions without waiting.
All eligible priority mail prescriptions are processed and mailed
within 24 hours of receipt, excluding weekends and holidays.
Pharmacy Service is now considering extending this program by
placing excessed US Postal Service mail boxes outside the hospital
on VA grounds. Veterans could either walk or drive up to the mailboxes
and drop off their prescriptions.
Benefits
This program has been quite successful in reducing the amount
of time veterans need to wait in the medical center. It has also
indirectly benefited a large number of other veterans by reducing
the number of patients using window services. Finally, it has
improved the efficiency of Pharmacy Service, since it requires
fewer resources to process a mail prescription than a window prescription.
Contact Person: Stephen D. Huckleberry, Pharm. D
Service: Pharmacy Service
Facility: Wilmington, DE VAMC & ROC
Number: (302) 633-5576 or FTS (700) 487-5576
Prior to 1994, homeless veterans in Milwaukee were served in the
VAMC Domiciliary or by local community providers, with the latter
offering rather limited shelter services. Veterans for whom domiciliary
care was not available experienced fragmented services and limited
support in breaking the cycle of homelessness.
In August 1994, the Milwaukee VAMC entered into a joint venture
with the Wisconsin Department of Veterans Affairs, the Milwaukee
Social Development Commission, and the Center for Veterans Issues
to establish Vets Place Central, a 65-bed veterans assistance
center offering safe housing, psychosocial treatment, vocational
rehabilitation, and other services. Vets Place Central's mission
is to assist veterans with the transition to stable, productive
community living. FTE and related funding were received from VA
Headquarters.
A second veterans assistance center was opened in July 1995 on
the grounds of the Wisconsin Veterans Home located in King, Wisconsin.
This center focuses on the needs of the rural homeless veteran
population, and provides transitional housing for up to 30 homeless
veterans along with alcohol and drug counseling, vocational rehabilitation,
and other services. The center is operated by VAMC staff, working
collaboratively with the Wisconsin Department of Veterans Affairs
and community- based veterans organizations.
Benefits
As a result of this partnership, comprehensive services are available
to homeless veterans in these two cities. Approximately 360 veterans
were housed at Vets Place Central between its inception in July
1994 and the end of FY 1995. Another 45 veterans received services
at the second center during the less than three months of FY 1995
that it was open. In addition, the VA has expanded its relationship
with state agencies, veterans service organizations, and other
community-based organizations. We believe that these veterans
assistance centers offer a new model for the care of homeless
veterans.
Contact Person: Barbara J. Gilbert, MSW
Service: Social Work Service
Facility: Milwaukee, WI VAMC
Number: (414) 384-2000 Ext 1826 or FTS (700) 383-1826
Studies have repeatedly shown that approximately one-third of
the shelter popula- tion consists of veterans, and that a large
proportion of these veterans has never utilized any VA services.
The Chillicothe VAMC, the Columbus Outpatient Clinic, and the
Columbus Vet Center jointly developed a pilot Homeless Veteran
Connection Program to expand VA services to veterans living in
Columbus shelters. The primary goal of the pilot program was to
have a VA representative visit the veterans at open shelters in
Columbus once a week. To accomplish this, each VA facility provided
social work services to one of the three open homeless shelters
in Columbus.
When social workers visited the shelters, they identified veterans,
engaged them in a screening process, quickly assessed their needs,
and then connected them to appropriate VA and community resources
for health care, housing, financial benefits, vocational services,
social and recreational activities, and transportation. The social
workers helped the veterans complete the following VA forms: 10-10M,
10-10F, and 10-10. A folder was developed for each veteran and
placed on file at the Chillicothe VAMC. Follow-up of referrals
was provided to those veterans who continue to reside in the shelter.
Benefits
During the first half of CY 1995, 60 veterans were seen in the
one shelter serviced by the Chillicothe VAMC, 154 referrals to
VA and community organizations were made, and 48 transportation
arrangements were made. Eighty-eight percent of the veterans seen
had not previously received services from a VA organization.
Despite the success of the pilot program, the available man-hours
were found to be insufficient to meet the needs of homeless veterans
in the Columbus area. Consequently, our medical center in September
1995 signed a contract with the American Red Cross to support
the equivalent of one full-time social worker to provide services
to homeless veterans. This has resulted in expansion of the Veteran
Connection Program to include other facilities where homeless
veterans congregate, such as those in the rural communities in
South Central Ohio, as well as the original three open shelters
in Columbus.
Contact Person: Matthew Williams, ACSW
Service: Social Work Service
Facility: Chillicothe, OH VAMC
Number: (614) 772-7005 or FTS (700) 975-7005
T he Bronx VA Medical Center serves a large, economically disadvantaged
population, many of whom may be entitled to a wide array of federal,
state, and municipal benefits. In addition, patients often request
referrals to unusual benefit programs, assistance with the filing
of applications, and follow-up to ensure the continuation of community
services. The volume and complexity of this workload required
more than the one social worker assigned to Ambulatory Care.
The Resources, Entitlement & Advocacy Program (REAP) was developed
in 1991 to maximize the services that could be provided to veterans
seeking assistance. VA volunteers, consisting primarily of retirees
and veterans in the second phase of a Substance Abuse Recovery
Program, are comprehensively trained by a NYC agency, ACES (Advocacy,
Counseling & Entitlements). Representatives from various agencies
such as Medicaid, Social Security, Public Assistance, and Food
Stamps supplement this training with specific information about
their respective programs, including eligibility, documentation
requirements, and filing procedures. All of the volunteers must
pass an examination before they become a REAP volunteer and are
supervised by a VA social worker, who is available to provide
additional guidance and information.
Housed in our Ambulatory Care Section, REAP volunteers see veterans
and their family members during all clinic hours. The office is
well stocked with innumerable forms, applications, and referral
materials that are invaluable to veterans seeking assistance.
Benefits
REAP has become a permanent fixture at the Bronx VAMC; during
FY 1994 there were 495 patient contacts. Social workers throughout
the medical center refer patients to REAP for practical assistance
with a myriad of problems. The program has allowed the assigned
ambulatory care social worker to concentrate on the more complex
clinical cases and to dedicate more time to our budding Primary
Care Practice.
Contact Person: Donna Festa and Ann Feder
Service: Social Work Service
Facility: Bronx, NY VAMC
Number: (718) 579-1637 or FTS (700) 884-5665
Specialty clinics at the Augusta VAMC are restructuring to improve
access and timeliness of patient services, as part of the facility's
movement toward primary care and the greater use of community
based services. In response to the task of downsizing clinic workload,
Social Work Service developed a Patient/Family Needs Checklist
Form to ensure that there are no gaps in patient services during
the transition period.
Upon arrival for a scheduled specialty clinic appointment, each
patient or a family member is given a checklist to complete while
waiting to be seen by the health care provider. When the forms
are completed, they are reviewed by social workers for identification
of needs or problems. Patients and families who request social
work assistance or check a need or problem are seen immediately
during the clinic appointment time. Referrals to community based
resources and VA programs are completed at that time. We also
make every effort to see each patient being discharged from a
specialty clinic with an identified concern or need for follow-up
care, on the day of the clinic visit. If a patient cannot be seen
that day, follow-up contact is made within 48 hours to address
patient and family concerns.
Benefits
The utilization of this checklist form has enabled social workers
to serve patients and their families in a more timely, efficient,
and effective manner. As a result, more patients who needed services
were seen, and care has been continued through appropriate resource
referrals.
Contact Person: Lena C. Richardson
Service: Social Work Service
Facility: Augusta, GA VAMC
Number: (706) 823-3908 or FTS (700) 251-2532
I n the past, patients placed in a community nursing home (CNH)
under VA contract were not consistently returned to this medical
center for scheduled clinic visits. In addition, ambulatory CNH
patients who were confused and those who required total care were
frequently not identified when they arrived for check in. Consequently,
escorts seldom accompanied these "at risk" patients
during their clinic visits.
Following discussions with Emergency Room, Ambulatory Care, and
Medical Administration staff, the following plan was developed
to address these issues:
Benefits
Follow-up surveys with Emergency Room, Ambulatory Care and Medical
Administration staff have revealed that the new system has been
effective with very few breakdowns. It has assured that our patients
receive the care they need and that our external customers, the
community nursing homes, receive timely information so that they
can better care for our veterans.
Contact Person: John Camarda
Service: Social Work Service
Facility: William Jennings Bryan Dorn VAMC, Columbia, SC
Number: (803) 695-6744 or FTS (700) 677-6744
T he Southeast Pennsylvania Network for Women Veterans includes
four VAMCs: Philadelphia, Coatesville, Lebanon, and Wilmington.
To better serve women veterans, the four medical centers wrote
a grant requesting funding for the Network to be one of the first
four Comprehensive VA Women's Centers. The proposal was accepted,
and in October 1993 the Network was established to provide comprehensive
gynecological and gender-specific care to a tri-state population.
The services include gynecology, screening for breast disease,
mammography, specialized women's mental health programs, and a
complete range of medical and surgical services.
Each site has its own gynecological nurse practitioner or physician
assistant who provides primary care and basic gynecological screening
and treatment to women veterans on-site, while the gynecology
physician staff (two 5/8 positions) is based at the Philadelphia
VAMC. Complex gynecological cases are referred to the Philadelphia
Gynecology Clinic, where the gynecologists are available to treat
Network women veterans five days a week; they also perform all
gynecological surgeries for Network patients. The Philadelphia
VAMC also houses an accredited Mammography Center and breast surgery
services. One of the gynecologists travels to each Network site
monthly to see patients, as well as to serve as a professional
mentor to the on-site gynecology practitioner. The other serves
as the attending gynecologist in Philadelphia.
All referrals are channeled through the Network Coordinator in
Philadelphia, who is responsible for appointment scheduling, patient
and records transfer, and coordination of inter-VAMC travel. Consult
information is sent from the clerk in the referring facility's
Women's Health Clinic by FAX and Patient Data Exchange (PDX) to
the Network Coordinator at the Philadelphia VAMC. She makes a
call directly to the appropriate specialty area (gynecology, surgery,
or mammography) to make the appointment. The referring nurse practitioner
is called back with all the necessary information and the time
and date of the appointment. Travel is provided to patients by
a daily inter-VA shuttle.
The success of this model has depended on the cooperation of staff
from the involved VAMCs. The Network hosts bi-monthly staff meetings
to discuss future directions and to address current problems and
issues. The staff have worked extremely well together during the
evolution of the Network and the first two years of implementation.
Benefits
The women veteran population receives comprehensive gynecological/gender-specific
care within the VA System. The women who have used the system
are quite pleased, as is indicated by the 47% increase in workload
from FY 1994 to FY 1995.
The Network is also a cost-effective model for delivering care
to women. Instead of having a gynecologist on staff at each VA
as well as gender-specific support systems, such as mammography
and cytology, there are two 5/8 physicians based in Philadelphia
who are able to successfully treat the Network population. The
Philadelphia VA Mammography Center and breast surgery services
are also available to all Network sites. Using the expedited referral
procedures described above, the turnaround time for making referral
appointments within the Network is one working day. Thus, the
Network allows the involved medical centers to efficiently care
for their women veteran patients within the "system,"
instead of using costly, non-VA fee-basis providers.
Staff receive the benefit of not being an isolated clinical specialty
at each medical center. Because of their involvement in the Network,
they receive support and supervision from the Network gynecologist
who is on-site monthly. They are also able to form collegial relationships
with the other Network gynecological providers.
Contact Person: Jennifer A. Harkins
Service: Women's Health Center
Facility: Philadelphia, PA VAMC
Number: (215) 823-4GYN or FTS (700) 481-5400
Note: Michael S. Rybicki of Wilmington VAMC and Suzanne White
Villarini, CNRP of Coatesville VAMC contributed to this write-up.
Surveys of client preferences as well as current research findings
led to establish- ment of the Wellness Program, a multidisciplinary
approach to health promotion and disease prevention designed to
promote the physical, mental, and spiritual wellness of women
veterans. The multiple strategies to enhance the health status
of women veterans include a Stop Smoking Program for Women Only,
support groups for weight loss and body image, individual screening,
education, and research related to health promoting behaviors.
The stop smoking classes uses the QuitSmart program developed
by Dr. Robert Shipley and are tailored specifically to the needs
of women. Overall program implementation involved outfitting a
patient education/resource room, educating staff on health promotion
strategies, enlisting staff in initiating support groups and classes,
and encouraging research in health promoting behaviors.
The Wellness Flow Sheet is a user friendly, single page tool that
provides a quick, accurate reference specifying the health promotion,
disease screening, and prevention needs of woman veterans. The
flow sheets are in all Women's Health Clinic charts and are used
to track targeted interventions for individual patients.
Benefits
Contact Person: Andrea Wilkes, MSN, RN, FNP
Service: Nursing Service
Facility: Durham, NC VAMC
Number: (919) 286-0411 Ext. 5073 or FTS (700) 671-0411 Ext 5073
T he Sepulveda Women's Health Center's (WHC) weekly women's health
clinic rotates among the medical center's three primary care teams.
Each patient is assigned a primary care provider from the team
responsible for her care. A female physician from the team always
staffs the clinic for triage and back-up. Staff from Radiology,
Gynecology, Surgery, Internal Medicine, Psychology, Psychiatry,
Social Work, Dietetics, and Education work together so that a
woman can have all of her health care needs met in one visit.
To increase privacy, a team will hold few other clinics when the
Women's Clinic meets and personal counseling sessions are held
in the separate offices of the WHC, away from all regular clinic
areas.
A full-time nurse practitioner reviews every patient's chart after
each clinic reviews all gender-specific test results, and makes
all presentations to the tumor board, ensuring that test results
are reported and followed up. A female clinical pharmacist provides
counseling and education for birth control, hormone replacement,
and all of the medications prescribed for female patients, thereby
providing a high level of patient education while also assuring
quality of care.
Victims of sexual trauma are known to make greater use of medical
and mental health services, and the WHC screens every patient
for a history of sexual trauma. Outreach is also made to female
veterans using other medical center services. One-on-one counseling
is offered to all patients with a history of sexual trauma. The
counselor is backed up by a female psychiatrist.
Benefits
Since the WHC opened two years ago, there has been a ten-fold
increase in the number of pap smears and mammograms performed.
Half of the patients offered counseling have begun regular visits
to the sexual trauma counselor. Providing female veterans a distinctly
separate clinic and counseling area affords them some degree of
privacy in what would other wise be a very male-dominated medical
setting.
Contact Person: Lisa Altman, MD
Service: Primary Ambulatory Care and Education (PACE)
Facility: Sepulveda, CA VAMC
Number: (818) 895-9555 or FTS (700) 966-9555
T he importance of annual breast and pelvic examinations and mammograms
is well documented in the medical literature. To meet this standard,
our Women's Preventive Health Care Clinic, after completion of
an annual examination, scheduled a return appointment in one year.
However, attendance at the next year's appointment was only about
50%, mainly due to the time lapse between the scheduling and appointment
dates.
To improve attendance, a reminder letter is now sent out about
two weeks prior to the scheduled appointment. A questionnaire
to be returned at the time of the clinic appointment accompanies
the letter; it requests information, such as the dates and results
of the last Pap test and the last mammogram, the date of the last
menstrual period, and hormone/contraceptive usage. The use of
the questionnaire allows the veteran to consult her personal records
to obtain this information. An educational needs assessment is
also included on the same questionnaire to help the veteran identify
specific issues that she wishes to discuss at the clinic appointment.
An inquiry regarding influenza and pneumococcal vaccination is
also included, as well as one about interest in a screening flexible
sigmoidoscopy.
Benefits
Attendance at scheduled Women's Clinic appointments for annual
examinations has improved to 90%. An increase in patient's rescheduling
of their appointments has also been noted. The information provided
to the physician concerning the woman's recent medical history
should be more accurate as a result of her having had an opportunity
to consult personal records beforehand. Also, the veteran is able
to raise more appropriate questions and concerns during the appointment
since she assessed her educational needs prior to the appointment.
Finally, increased immunization and use of flexible sigmoidoscopy
have resulted.
Contact Person: Patty Evans, RN
Service: Women Veterans Service
Facility: Fargo, ND VAMC & ROC
Number: (701) 232-3241 Ext 3597 or FTS (700) 783-3597
Results of quality improvement monitoring revealed that less than
7% of female patients at our hospital received mammograms in the
previous fiscal year. This rate was significantly reduced from
previous years when a portable mammography unit was available
on station to provide mammograms. However, use of the portable
unit had to be discontinued as it did not meet current standards,
and attempts to obtain a free-standing mammography unit were unsuccessful.
A process action group, formed to examine this issue, interviewed
woman veterans to find out what barriers were preventing them
from receiving mammograms. The veterans reported that they were
unable or unwilling to travel to another VAMC to receive a mammogram
because of the time or inconvenience required. They also reported
feeling uncomfortable traveling on the van or waiting in Radiology
as they frequently were the only female present.
We contacted the American Red Cross, who helped us locate a local
medical center that had an American College of Radiology accredited
mammography unit. A fee-basis contract was developed to allow
female veterans to be scheduled for mammograms at the community
hospital. Mechanisms were established for entering mammography
results into DHCP and notifying VA providers of any abnormal findings.
Benefits
The number of mammograms performed increased 400% to over 111
in the past year. Female veterans who received mammograms were
surveyed and were uniformly positive in praising the ease of access,
the personnel performing the mammograms, and the environment.
Contact Person: Katherine E. Dong, MS
Service: Women Veterans Coordinator
Facility: North Chicago, IL VAMC
Number: (708) 578-3759 or FTS (700) 384-4644
We surveyed over 400 consecutive women veteran primary care patients
using outpatient clinic services at our Women's Health Center.
Approximately 30% stated that they had suffered sexual trauma.
Many of these women experienced symptoms of depression, insomnia,
pain, and anxiety that may have been connected to their sexual
trauma. We developed a time limited group using cognitive behavioral
and psycho-educational techniques to help these women move from
being victims to survivors to victors over their sexual trauma
experience.
Benefits
Data from surveys of the two groups who piloted the 14 week program
indicated that:
Contact Person: Marian I. Butterfield, MD, MPH
Service: Psychiatry Service
Facility: Durham, NC VAMC
Number: (919) 286-0411 Ext. 7302 or FTS (700) 671-0411 Ext 7302
P rior to computerization, carbon copies of laboratory results
were placed in physicians' boxes in Laboratory Service. With the
advent of computers, printed results were distributed to mailboxes
in the ordering physicians' services. Given the considerable costs
in personnel time and paper, computerized distribution seemed
preferable. Two staff and one house staff physician developed
and pilot- tested a system that returned results directly to the
ordering physician. The program was subsequently refined so that
providers are prompted with the results of laboratory tests they
or their firm ordered whenever they sign on. The normal range
and the patient's phone number is also displayed, as is the status
of tests that are still being processed. The provider can then
take one of several actions; the default is to delete the result
from the program. Alternatively, one can forward the result to
another provider, look up past results to check for trends, print
the results, suspend it for later viewing, or quit. A surrogate
can also be designated to receive the results during leave or
other absences.
Benefits
The system is very user friendly and widely accepted by physicians.
It ensures a measure of accountability because it records when
the result has been seen by a provider. Also, considerable resources
have been saved in pager and personnel time previously required
for the distribution of laboratory results.
The program has been exported to other facilities. They report
great utility for staff and house staff who rotate to other medical
centers; on their return to VA, they can follow the laboratory
tests they ordered without maintaining their own list of results
they need to access and review. Also, the display of phone numbers
makes it easy to contact patients.
Contact Person: David Lee, MD
Service: Chief of Staff
Facility: Boise, ID VAMC
Number: (208) 338-7201 or FTS (700) 554-7201
Our previous procedure for ordering x-rays could lead to transcribing
errors. First, the physician would write the order on the progress
note and complete the radiology order form by writing the name
of the exam and the reasons for ordering it. The MAS clerk would
then attempt to read these handwritten entries and order the test
in DHCP. Inaccuracies in recording the exam and the reasons for
ordering it inevitably occurred and were probably unavoidable.
A new radiology form was developed to address this problem. The
front side of the form lists all the radiology procedures that
are performed at the clinic; the clinician checks those that are
needed. On the back side, a clinical history checklist is provided,
and the clinician checks off the reasons for ordering the tests
for a particular patient.
Benefits
The new form involves an objective transfer of information from
the radiology order sheet to DHCP by the MAS clerk. The possibility
of an error occurring during this transfer has been significantly
reduced. The change has also resulted in improved efficiency among
MAS staff, and has decreased their frustration since they no longer
have to spend time deciphering provider handwriting.
Contact Person: Mukesh Jain, MD
Facility: Canton, OH VAOPC (Cleveland, OH VAMC)
Number: (216) 489-4617 or FTS (700) 290-3800 Ext 4617
Since delayed actions may have tragic consequences, the transmission
of abnormal radiology reports to health care providers has to
be a fail-safe process. However, the logistics can be overwhelming
at institutions employing large numbers of residents, fellows,
and part-time staff members, particularly in the outpatient area.
At VA Connecticut, we utilize several common systems to disseminate
radiology reports: telephone access to dictations, VA view alerts,
transcription of reports into DHCP, and printing of reports in
the Health Summary. However, none of these systems have addressed
the need to rapidly notify more than one provider regarding an
abnormal report, to avoid delays when the requesting practitioner
leaves the VA.
Three years ago, we modified our system as follows:
Benefits
It is difficult to quantify the impact of the revised system,
since the frequency and clinical impact of delayed actions are
difficult to track. However, we feel that this procedure is a
valuable addition to a multi-level effort to ensure transmission
of critical clinical data.
Contact Person: Kenneth L. Cohen, MD
Service: Ambulatory Care Service
Facility: VA Connecticut - West Haven Campus
Number: (203) 932-5711 Ext 4483 or FTS (700) 428-4483