Patient- and Family-Centered Care: Approaches for Children and Seniors
Patient- and Family-Centered Care: Approaches for Children and Seniors
On July 22, 2014, the Innovations Exchange held a Web event titled Patient- and Family-Centered Care: Approaches for Children and Seniors.
This was the second Web event in a series designed to describe patient- and family-centered care, share novel experiences, and explore lessons learned.
Judi Consalvo, Program Analyst, Center for Evidence and Practice Improvement, Agency for Healthcare Research and Quality
Judi Consalvo serves as a Program Analyst in the Center for Evidence and Practice Improvement at the Agency for Healthcare Research and Quality (AHRQ). She is the project lead for the AHRQ Health Care Innovations Exchange and has been affiliated with this program since its inception. Ms. Consalvo also serves as a grant project officer and a conference grant reviewer.
Beverley H. Johnson, President and Chief Executive Officer, Institute for Patient- and Family-Centered Care
Ms. Johnson has provided technical assistance and consultation for advancing the practice of patient- and family-centered care to over 250 hospitals, health systems, federal, state, and provincial agencies, military treatment facilities, and community organizations. She assists hospitals and ambulatory programs with changing organizational culture, and facilitates visioning retreats and the integration of patient- and family-centered care concepts in policies, programs, and practices, as well as in facility design and the education of health care professionals. Ms. Johnson, who is invited to speak worldwide, has co-authored numerous books and publications on patient- and family-centered practice in pediatrics, newborn intensive care, maternity care, emergency care, geriatrics, and other aspects of adult health care. She has served as executive producer for award winning documentary films and videos and is the recipient of numerous awards.
Michelle Rickerby, MD, Co-Director, Hasbro Children’s Partial Hospital Program, Clinical Associate Professor, Department of Psychiatry and Human Behavior, The Warren Alpert Medical School, Brown University, Providence, RI
Dr. Rickerby is Psychiatric Co-Director of the Hasbro Children's Partial Hospital Program and Clinical Associate Professor in the Department of Psychiatry and Human Behavior of the Warren Alpert Medical School of Brown University. Her career since completing child psychiatry residency training at Brown in 1996 has been focused on family-based treatment of complex pediatric illness, including eating disorders, chronic illness complicated by non-adherence, and somatoform disorders. She is Co-Director of family therapy training for the child psychiatry residency and the triple board residency at Brown.
Diane DerMarderosian, MD, Pediatric Co-Director, Hasbro Children’s Partial Hospital Program, Clinical Assistant Professor of Pediatrics, The Warren Alpert Medical School, Brown University, Providence, RI
Prior to her current role as Pediatric Co-Director of the Hasbro Children's Partial Hospital Program, Dr. DerMarderosian served as Medical Director of the Hasbro Eating Disorders Program. In addition to her expertise in caring for patients with eating disorders, she specializes in working with patients with complex medical and psychological illnesses and their families. Dr. DerMarderosian serves on the medical advisory committee for the Multi-Service Eating Disorders Association (MEDA), the Hasbro Patient- and Family-Centered Care Steering Committee, and the Pediatric Faculty Development Steering Committee, and is Medical Director of Reach Out and Read Rhode Island (RI). She has been recognized for her excellence in teaching and has won several resident teaching awards. Dr. DerMarderosian graduated Amherst College with a BA in anthropology. She attended Mount Sinai School of Medicine, where she was selected to be part of the humanities and medicine program, and completed her residency training in pediatrics at The Warren Alpert Medical School of Brown University in 1999.
Judith Rogers, PhD, MSN, RN, President, Holy Cross Hospital, Silver Spring, MD
Dr. Rogers has served as President of Holy Cross Hospital since 2003. Prior to her current role at Holy Cross, she served as Senior Vice President of Operations, Vice President of Women and Children’s Services, Chief Nursing Officer, and Vice President of Patient Care Services.
Patient- and Family-Centered Care: Approaches for Children and Seniors
Web Event July 22, 2014 Follow this event on Twitter Hashtag: #AHRQIX
Image 1 (top)– U.S. Department of Health and Human Services Logo
Image 2 (middle) – Agency for Healthcare Research and Quality (AHRQ) Logo – will be used as header on following slides.
Image 3 (bottom right) – AHRQ Innovations Exchange Logo – will be used as footer on following slides.
Using the Webcast Console and Submitting Questions
Image of attendee console with an arrow pointing to the box to type in questions and another arrow pointing to the Q&A widget.
What is the Health CareInnovations Exchange?
- Publicly accessible, searchable and downloadable database of health policy and service delivery innovations
- Searchable QualityTools
- Successes and attempts
- Innovators' stories and lessons learned
- Expert commentaries
- Learning and networking opportunities
- New content posted to the Web site every two weeks
- Sign up at http://innovations.ahrq.gov
Innovations Exchange Web Event Series
- Archived event materials are available from the Events & Podcasts tab at http://www.innovations.ahrq.gov. These include:
- The May 2014 Web event in this series, “Patient- and Family-Centered Care for Adults with Chronic Conditions”
- Today's Web event will be available within two weeks
Patient- and Family-Centered Care: Approaches for Children and Seniors
Beverley H. Johnson
Institute for Patient- and Family-Centered Care
Patient- and Family-Centered Core Concepts
- People are treated with respect and dignity
- Health care providers communicate and share complete and unbiased information with patients and families in ways that are affirming and useful
- Patients and families are encouraged and supported for participation in care and decision-making at the level they choose
- Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care
Patient- and Family-Centered Core Concepts
Patient- and family-centered care is working with patients and families, rather than to or for them
Image 1 (left): Image of physician consulting with patient in an office.
Image 2 (right): Image of physician consulting with a male patient and his wife in a hospital.
Why Patient- AND Family- Centered Care?
- Individuals who are most dependent on health care are most dependent on families:
- Those with chronic conditions
- The very young
- The very old
- Families are allies for quality and safety by:
- Providing constant support across settings and assisting with transitions of care
- Participating in developing care plans and supporting patients in following plans
Image 1 (left): Picture of a Hispanic family.
Image 2 (right) : Picture of a nurse checking heart beat of an elderly man.
Hasbro Children's HospitalProvidence, Rhode Island
- Family Advisory Council
- Communicates needs of families
- Fosters partnerships among families and health care professionals
- Provides mechanism for families to provide input for policies, programs, and facilities
Hasbro's Family Advisors
- Family advisors serve on the following:
- The Patient- and Family-Centered Care Steering Committee
- The Healthy Hospital Initiative
- The Zero Harm Committee
- The Safety and Quality Committee
- The Family Rooms Subcommittee
Hasbro's Family Advisory Council
- Family Advisory Council Current Priorities:
- Alternative Medicine Programming: working with Palliative Care Service
- Safety and Security: working with Security Department to enhance building security
- Nutrition: working with Food and Nutrition Department to improve healthy options for children and families
- Physical Environment: re-sign outdoor play area
Hasbro's PFCC Rounds
- Patient- and Family-Centered Care (PFCC) Rounds
- Shadowed physicians and multidisciplinary team members on daily PFCC rounds
- Created a video about rounds that will be used for teaching; also available on the GetWell Network for patient and family education
Family-Based, Integrated, Day Treatment for Children and Adolescents with Complex Pediatric Illness
Michelle Rickerby, MD Hasbro's Children's Hospital
Diane DerMarderosian, MD Hasbro's Children's Hospital
- Patients and families with whom we partner
- Program's entire multidisciplinary team
- Program Founders
- Tom Roesler, MD
- Pamela High, MD
- Patient and Family Centered Care Manager
- Fran Pingitore, MSN, RN, PCNS-BC
Hasbro Children's Partial Hospital Program
A joint program of the Department of Pediatrics and Division of Child Psychiatry that treats children with both medical and emotional illness
Image 1 – Picture of the Partial Hospital Program Mural
What We Hope to Accomplish
- The Hasbro Children's Partial Hospital Program (HCPHP) treatment model
- We serve patients and families by:
- Joining with families “where they are”
- Recognizing parents as the experts on their children and patients as the experts on their own experiences
- Coordinating care and services from a multidisciplinary team that includes parents
- Using day treatment to maximize sustainable home-based success
“The family needs to be part of the team that supports the patient's recovery. This collaborative effort between staff and family is critical because the family knows the child best. The family is able to communicate their observations to the staff. This helps the staff and hopefully quickens the recovery process.” - “EC,” parent
Structure of the Program
- Eight hours a day, 5 days a week
- Two age groups: 6 to12 years and 13 to18 years
- Median length of stay: 18 to 20 days
- Approximately 190 admissions per year
- Presence of both a medical illness and a psychiatric condition affecting the medical problem
- Patient stable; does not require 24-hour hospitalization
- Inpatient discharges, if patient is high risk of re-hospitalization within days or weeks
- If patient was treated on outpatient basis, medical and psychiatric treatment failed and the patient has significant impairment of daily activities
- Inpatient admission is anticipated within days or weeks because of deteriorating condition
Typical Patient Experiences
- Eating disorders
- Inflammatory Bowel Disease
- Migraine headaches
- Somatoform Disorders
- Disordered eating
- Medical non-adherence
- Functional syndromes
- School avoidance
- Coping with chronic illness
- Medical child abuse
- Social workers
- Milieu therapists
- Collateral providers
- Patient and family
- Child and family psychiatrists
Meeting Families Where They Are
and Supporting Empowerment
- Understanding of the illness
- Impact of illness on family relationships
- Pre-existing challenges
- Identifying opportunity amidst crisis
Image 1: Image of physician consulting with a mother and her child.
“Family-Based” Decision Making
- Not simply “involving the family”
- Not just using family therapy as a modality
- Understanding that the family and patients are experts
- Making every decision from the perspective that the family's understanding of the illness and family relationships constitute a powerful force in illness management/recovery
- Not simply the concept of integrating physical and psychological issues
- The integration of modalities (pediatric care, psychotherapy, case management, psychopharmacology) through consistent provider communication and provision of coordinated messages to families and patients
Family Empowerment Experiences
- Daily nursing support and education
- Pediatric medical monitoring /treatment with integral involvement of patients and families
- Nutrition education meetings
- Family support groups
Family Empowerment Experiences
- Parent training within skill-building curriculum
- Family therapy
- Close collaboration with the family's healthcare providers; both the patient's and those treating parents/siblings
- Support family members in caring for themselves
The “Good News” of High Intensity Challenges
- A trusting partnership with patients and families is critical to improving patient outcomes
- If we “know where we are,” we know what to do
- Consistent messages matter and are powerful
- Excellent provider collaboration is a strong force in supporting patient/family success
- Any painful challenge/symptom/illness is improved with an empowered set of beliefs and empathic relationships
The Inpatient Setting
- AHRQ study of Geriatric Academic Rounds at the bedside with the patient and family at The Christ Hospital, Cincinnati, OH
- Patient and family advisors were a part of this research and the practice change
Image 1: Picture of a geriatric academic round at the bedside with a patient.
Hospital Care Unusually Stressful for Older Patients
- Social Isolation is a risk factor
- Research findings:
- Isolating patients at their most vulnerable times from the people who know them best, places patients at risk for harm and costly unnecessary care*
- For many older patients, hospitalization for acute/critical illness is associated with reduced cognitive function*
Patient- and Family-Centered Approaches for Older People
Families and other care partners are more keenly aware of any change in cognitive function than hospital staff and, therefore, are a valuable resource during hospitalization.
Better Together–Partnering with Families
- “The family is respected as part of the care team—never visitors—in every area of the hospital, including the emergency department and the intensive care unit”
Leape, L., Berwick, D., Clancy, C., & Conway, J., et al. (2009). Transforming healthcare: A safety imperative. BMJ's Quality and Safety in Health Care. Available at: http://qshc.bmj.com/content/18/6/424.full.
- Campaign to eliminate restrictive visiting policies in 1,000 hospitals by 2017 — to access an array of resources to begin a process of change: www.ipfcc.org/bettertogether/
Leadership to Build A Patient- and Family-Centered System of Care
Atlanta's Emory Healthcare's Goal: Transform health and healing by developing and implementing innovative, patient- and family-centered care, research, and teaching models
- Designed clinical space to facilitate interdisciplinary, patient- and family-centered approach to care delivery
- Created and implemented 2-3 specialty-based patient and family advisory councils in each facility; appointed advisors to at least 5 quality and facility committees/initiatives system-wide
- Over 2-yr period, patient experience scores improved 40 percentage points for overall nursing care and for how well pain was controlled
Further Evidence of the Value of Patient and Family Partnership
Patient and family advisors participated in facility design planning AND in the design of care processes for Emory's new Orthopaedics & Spine Hospital at Emory. Results:
- Patient satisfaction has been at or above 96th percentile since the hospital opened in 2008
- Length of stay is one day shorter than benchmarked specialty hospitals across U.S.
- Patient and family advisors continue to participate in hospital councils and other change processes
Building Partnerships in Emergency Care
Contra Costa Regional Medical Center held “value stream mapping” event to improve behavioral health emergency care; involved patient and family advisors. Results:
- 50% reduction in average number of patients leaving the emergency department (ED) prior to receiving care
- Saved 255 staff hours/month spent obtaining patient medical clearances in ED
- Reduced assaults/aggressive acts in ED
- Percent of patients returning home with a full discharge plan grew from 50% to 90%
- Reduced % of patients discharged on multiple psychotropic drugs
Holy Cross Hospital Seniors Emergency Department
Judith Rogers, PhD, MSN, RN Holy Cross Hospital
Holy Cross Hospital Characteristics
- Full service acute care hospital founded in 1963 by the Sisters of the Holy Cross
- 1,366 member medical staff and 442 licensed beds, including 46 neonatal intensive care units; second largest hospital in region
- Only teaching hospital for medical education in County
- Revenue of $387 million
- Community benefit of $48 million, including $26 million of financial assistance
- 31,981 discharges and 182,593 outpatient registrations
- 90,232 emergency visits
- 3,393 employees; 68.3% minority
- Workplace Excellence award for 14 consecutive years
- Stable workforce; no layoffs
- Culturally and ethnically diverse; Of the 1.7 million residing in the overall service area:
- 37% Black, 31% White, 19% Hispanic, 10% Asian, 3% other
- 12% Seniors 65+ (210,813)
- Rapidly aging; seniors 65+ projected to grow 23% by 2018, compared to 2% for ages 0-64
Purpose of Seniors Emergency Department (ED)
- Focus on improving:
- Patient care
- Patient experience
- Staff engagement and satisfaction
- Health care resource allocation
- Readmission rates
- Complication rates
- Length of stay
- Payment denials/reimbursement risks
Seniors ED Goals
- Optimize utilization of both in- and outpatient resources
- Establish effective and expedient outpatient resource access and care transitions
- Prepare for the fact that acute care episodes are often accompanied by:
- Functional decline
- Increased dependency
- Increased morbidity
Focus on Patient and Family
- Respect and dignity
- Information sharing
- Collaborative decision making
- Participation as part of the team
- Create constant support systems
The Value of Family Engagement
- We learn from the family
- Family helps steward the plan of care
- Better outcomes are supported by greater family engagement
- To care for Mary was to care for something larger
- Caring for Mary's husband was part of that something larger
- When family is not present or involved, care is compromised:
- Difficulty in providing optimum acute care services
- Questionable follow-up
- Challenged transitions of care
Making the Connection
- Create a sustainable infrastructure
- Partner with loved ones in the care of seniors
- Create a “one person” interface
- Supports the mission of Holy Cross Health
- Be the most trusted provider in the community
- Organization-wide focus on seniors
- Partner with Erickson School for all-leader engagement
- Acute Care of Elders: includes multidisciplinary rounds three times per week for all patients included in program
- Seniors Emergency Department
- Seniors Ambulatory Surgery Department
- Caregiver support group
- Geriatric Resource Nurse Council
- Leadership Selection
- Emergency department/geriatric experience
- Staff selection (dedicated unit staff)
- Staff must want to be there; embrace geriatric care
- Geriatric-trained nurse practitioner and social worker
- Staff clinicians (All registered nurses must complete updated Geriatric Emergency Nursing Education program by Emergency Nurses Association)
- About 75 nurses within the organization have completed Nurses Improving Care to Health System Elders training to be a Geriatric Resource Nurse
- All Seniors discharged from the Emergency Department receive a call back from social worker
- Facilitates follow up with primary care physician
- Offers further services (if required)
- Provides family support as needed (respite care)
- Polypharmacy review continues for all patients on 5 or more medications (approximately 80% of all patients)
Image 1 (left): Screen shot of Institute for Patient-and Family-Centered Care (IPFCC) Home Page
Image 2 (right): Screen shot of the IPFCC Better Together Home Page
- Cacioppo, J. T., & Hawkley, L. C. (2003). Social isolation and health with an emphasis on underlying mechanisms. Perspectives in Biology and Medicine, 46(3), S39-S52.
- Clark P. A., Drain, M., & Malone, M. P. (2003). Addressing patients' emotional and spiritual needs. Joint Commission Journal on Quality and Safety, 29(12), 659-70.
- Ehlenbach, W. J., Hough, C. L., Crane, P. K., Haneuse, S. J., Carson, S. S., Curtis, J. R., & Larson, E. B. (2010). Association between acute care and critical illness hospitalization and cognitive function in older adults. JAMA, 303(8), 763-77.
- Spencer, P. (2008). The security case for patient and family centered care. Journal of Healthcare Protection Management, 24(2), 1-5.
- Spencer, P. (2012). Security's Role in PFCC. Journal of Healthcare Protection Management, 28(2), 30-34.
- Guide to Patient and Family Engagement in Hospital Quality and Safety
- Patient Centered Medical Home (PCMH) Resource Center
- Engaging Patients and Families in the Medical Home
- Strategies to Put Patients at the Center of Primary Care
Image 1 (top): Screenshot of AHRQ's Guide to Patient and Family Engagement in Hospital Quality and Safety web page.
Image 2(bottom): Screenshot of the Patient Centered Medical Home Resource Page.
The Innovations Exchange
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Frontline Innovators on Providing Patient- and Family-Centered Care Videos
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JUDI CONSALVO: Good afternoon. On behalf of the Agency for Healthcare Research and Quality, I'd like to welcome you to our Web event entitled, “Patient- and Family-Centered Care: Approaches for Children and Seniors”. I'm Judi Consalvo with AHRQ’s Center for Evidence and Practice Improvement. And we're very excited about today's topic and glad to see that you share our enthusiasm. We have over 600 registered for this event today.
Next slide. Before we begin, I would like to introduce you to our Webcast console. You can resize your console to fit your entire browser window. All the components on the console can be resized, moved, and minimized into the menu dock at the bottom of the console. If the slides are too small, click on the lower right hand corner of the slide window and drag your mouse down to make it larger.
Twitter functionality is available in the console for today's Webcast. Please feel free to participate using the hashtag #AHRQIX. I would also like to remind you that if you experience any technical problems, you may click on the question mark button at the bottom of the screen to access a help guide, or click on the Q&A button at the bottom of your screen to contact us directly with your question. Local staff will work with you to resolve any issues.
After each presentation, we will hold a 10 minute Q&A discussion based on questions that you submit. You can submit questions at any time during the presentation. Simply click on the Q&A button at the bottom of your screen. Then type your question into the Q&A box and select “Submit”. We welcome your questions and comments on the upcoming presentation and look forward to an engaging dialogue that will promote the spread of health care innovations.
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Next slide, please. So what is the Health Care Innovations Exchange? The presenters that you will hear from today are innovators from AHRQ's Health Care Innovations Exchange. For those of you who are new to the Innovations Exchange, I'll take just a minute to give you an overview. AHRQ created the Exchange to speed the implementation of new and better ways of delivering health care. The Exchange offers busy health professionals and researchers a variety of opportunities to ultimately adopt evidence based innovations and tools suitable for a range of health care settings and populations.
The Innovations Exchange Website includes a searchable database of QualityTools, as well as profiles outlining innovations in service delivery and in policy. The Exchange also contains both successes and attempts, innovator stories and lessons learned, and expert commentaries.
To assist you in implementing these innovations, AHRQ also supports learning and networking opportunities, such as Web seminars, Tweet chats, and podcasts. We post new content to the Website every two weeks on a range of topics and hope that you will sign up to stay connected with us, if you have not already done so.
Next slide. For the Innovations Exchange Web event series, this is the second in our patient- and family-centered care series. The first, entitled “Patient- and Family-Centered Care for Adults With Chronic Conditions” was held on May 20th and described the efforts at Georgia Regents Medical Center. Georgia Regents implemented a program of patient advisers that participate in hospital councils, committee, staff training, and other activities. These advisers contribute to improve patient satisfaction and better organizational performance.
You can watch the two minute video highlighting the Georgia Regents innovation by visiting our Web site, www.innovations.ahrq.gov and clicking on the tab labeled Videos. The Web event is also available for viewing on our Web site. The Web site also holds an archive of our past Web events, podcasts, and Tweet chats. And we invite you to take a look at it in your practice. A copy of today's Web event will be available on our Web site within two weeks.
So let's turn to my agenda for today. It is my pleasure to introduce our moderator, Bev Johnson, President and Chief Executive Officer of the Institute for Patient- and Family-Centered Care. Ms. Johnson has provided technical assistance and consultation for advancing the practice of patient- and family-centered care to over 250 hospitals, health systems, Federal, State, and provincial agencies, military treatment facilities, and community organizations. She assists programs seeking to change organizational culture. And she facilitates the integration of patient- and family-centered care concepts into policies, facility design, and educational programs for health care professionals. Bev?
BEV JOHNSON: Thank you, Judi. And it's wonderful to have this opportunity to have a conversation with so many people across the country about innovations related to patient- and family-centered care. And today to explore it in more depth for children and youth and with seniors, particularly in emergency departments. As foundational to our discussion today, I just would like to review the core concepts of patient- and family-centered care so we have a shared understanding of this approach.
Basically, patient- and family-centered care is an approach to the planning, implementation, and evaluation of health care in mutually beneficial partnerships among patients, families, and health care professionals across all disciplines. And this approach really respects relationships. And that those relationships are really, the strength of those relationships, is around respect and dignity. And that's respect and dignity for everyone, whether it's a young child, their family, a frail, elderly person, their family, and also those who work in hospitals or clinics. We have to work together and work together with a sense of respect and dignity for all.
The second core concept is how we share information with people; that we share information with them in ways that are useful and affirming. And for the patient- and family-centered practice, we know we get the best outcomes when we encourage and support the active participation of patients and families in their own care. And we connect with them at the level they prefer and encourage and them and support meaningful participation.
And lastly, it's a collaboration with patients and families in making improvements to really ensure that we have patient- and family-centered care implemented in all of our facilities across all settings. We need to partner with patients and families in program development, in health redesign, education of professionals, and even in research.
A simple definition, and I think you will hear it so much reflected in the two, three wonderful speakers we have about the two programs you're going to hear about. Patient- and family-centered care is working with patients and families, rather than doing things just to and for them. I think also, regardless of the setting where you work, you realize that to care effectively for patients, particularly for patients who may be vulnerable because of a chronic condition, they're very young, they're very old, that these people are often very dependent on either family or other care partners in the community. And so we need to think about, through our care practices, how we can involve, and support, and bring in the family, broadly defined, to really be allies for quality and safety in ensuring that we're getting the best outcomes.
We are fortunate today and we're going to be hearing in depth about a particular program at Hasbro Children's Hospital. But the hospital more broadly is very committed to patient- and family-centered practice and to partnering with families in a number of ways. So they have a family advisory council that provides a structure so there can be a dialogue with clinicians, and staff, and leaders about the needs, and priorities, and preferences of families, what their perception of the care experience is, and how it can be improved. That this council provides a structure so that these partnerships can really be meaningful and effective. And they are having a direct impact on policies, programs, and facilities.
I think you might find it interesting where some of the Hasbro advisers are working. And a best practice is really to not just have a council, but to bring patient and family advisers working side by side with you on key working committees and task forces. So at Hasbro, they are working, there is an oversight steering committee, which I think is very important when you're really trying to transform the culture of an organization, to have this leadership kind of committee that can encourage, support the work, and even help remove barriers.
But the family advisers, one of the initiatives they're working on is trying to promote the hospital as a healthy environment. They're working to reduce harm, so very ambitious zero harm committee includes family advisers, also on the safety and quality committee. And they are looking also into improving support to support family presence, and so there are family rooms throughout the facility.
The additional current priorities are a part of the palliative care service, focusing on alternative medicine programming. And I think this is really important. In our work in lots of hospitals around the country, and in community programs, often the public doesn't even understand the term “palliative care”. And by having family advisers be part of this, they can help translate and help those of us who work inside health care organizations translate these concepts in ways that are useful and meaningful to the public.
They're also working side by side with security. Again, this is another wonderful way that you can partner with families to help preserve that the facility is welcoming and inviting, but also safe for everyone, patients, families, and staff. They're also partnering with the nutrition department to improve healthy options, and I bet this is involving children as advisers as well. And the opportunities they have for improving signage in the outdoor play area, so there's a whole range of interesting projects their advisers are working on.
I think this last innovation is particularly important in that it is a major lever in, particularly, academic medical centers. If we can change how teaching clinical rounds are conducted, that they're conducted across disciplines and with patients and families. And the patient and family advisers have been very involved at Hasbro to shadow physicians and the team conducting the daily rounds, and providing feedback. And they have now developed a video that will be used for teaching. Because this is a new way for faculty and trainees to work. So we need to support this change in practice.
But they're also going to be using this to educate patients and families in using the GetWellNetwork, so that they can learn right at the bedside. I'm really very excited. I think this is a lever for dramatic change in the patient experience in hospitals. I now would like to introduce to you two wonderful people that are going to talk about a very innovative program at Hasbro Children's Hospital, the family-based, integrated day treatment for children and adolescents with complex psychiatric illness. And as they will describe, this is not only physical illness but mental health and behavioral health issues are addressed in this clinic together.
And speaking with us today, we have Michelle Rickerby, who is the psychiatric co-director of the Hasbro Children's program and is a clinical associate professor in the Department of Psychiatry and Human Behavior at the Brown University Medical School. She has a lot of expertise in family-based treatment of complex pediatric illness. And she is also the co-director of a family therapy program for child psychiatry residencies and the Triple Board Residency at Brown.
Joining Michelle today is Diane DerMarderosian. And she's the pediatric co-director of this program. And she worked previously as the medical director of a Hasbro eating disorders clinic. Diane also serves on the patient- and family-centered steering committee at the hospital. And she is on the pediatric faculty development steering committee as well. So before you get a chance to talk directly with Michelle and Diane, they're going to share their thoughts on a video. And then they will join the conversation today.
-Jen was a 15-year-old young woman who was diagnosed with diabetes when she was a toddler.
-She was struggling with episodic symptoms including getting short of breath, sometimes feeling very panicky, going through periods of feeling suicidal. And in addition, of course, her father was deployed in the Middle East, leading to the family feeling anxious and panicked anyway.
-It was keeping her from going to school. And actually, she ended up having several emergency room visits. The doctors who referred her to us felt like we could help sort out what was really going on for Jen and support the family in helping her getting back to her life. Jen came to our program, which is a multidisciplinary med site day treatment program which runs five days a week and modulates the school day.
-What we're doing is treating kids in context.
-And most importantly, really acknowledging that when we treat kids, we really are treating their families. The level of her blood sugar was quite high. That can really contribute to kids not feeling well, to being fatigued. We were able to provide extensive education for Jen and her family around diabetes.
-Jen was a teenager who had struggled with a lot of social anxiety. When teenagers and younger kids are at our program, it may represent the first time ever in their lives they've been able to openly talk about their illnesses with peers.
-What we really know to be the case is that if we don't really incorporate the whole family into the treatment, that we're really not going to support kids in an optimal way.
-Although her father was stationed in the Middle East at the time, we were able to arrange having him involved in a family meeting by Skype.
-Where everybody was really able to give Jen the message that they wanted to see her thrive. They wanted to see her get back to school. So after four weeks, control of her diabetes was much improved. And Jen was able to transition back to school and able to function like any other teenager in school and with her extracurricular activities.
-The adult medicine and psychiatry world has a lot to take from our experience, as well.
-If providers of all types, medical providers for different disciplines, psychological providers, everyone who's involved in taking care of the whole family, don't talk to one another, patients aren't going to receive optimal care. My name is Diane DerMarderosian.
-And my name's Michelle Rickerby. We believe that joining with families to treat the whole child leads to healthier kids.
[END VIDEO PLAYBACK]
DIANE DERMARDEROSIAN: Thank you, Bev, for that kind introduction and for all of the amazing work you do in this area. We're really honored to be part of this important program. We're able to do the work we do because we do it as a team. And the team includes our incredible patients and families, with whom we have the privilege to partner, our amazing Hasbro multidisciplinary team, our program founders, Tom Roesler and Pam High, and as you mentioned, Fran Pingitore, who's our Patient- and Family-Centered Care Manager at Hasbro, who played an invaluable role in establishing and growing our program. And now through her passion and expertise has established and fostered a patient- and family-centered culture throughout Hasbro Children's Hospital and beyond.
The Hasbro Children's Partial Hospital Program is a joint program of the Department of Pediatrics and the Division of Child Psychiatry. And we treat children with both medical and emotional illnesses that co-present. It's an integrated program both from a system standpoint and also in practice. And our foundation is a mutually beneficial partnership that's established between providers and families. It's this partnership and shared decision making that are critical to our mission of supporting empowerment towards the ultimate goal of patients and families not only getting their lives back, but also thriving.
Some of the ways we work to do this with families are joining with them where they're at, recognizing parents as the experts on their own children, and patients as the expert on their own experiences, coordinating care and services as a multidisciplinary team that includes parents, and utilizing day treatment to maximize sustainable home base success even beyond the time patients are in the program. The most valuable feedback we receive comes from patients and their families. In her own words, this parent highlights what she felt was most helpful in supporting positive movement for her family, and her daughter. And that's the collaboration between staff and family.
By respectfully partnering with patients and families, we're able to better understand the illness and the illness beliefs that exist, as well as support family strengths and relationship. And this partnership and this approach are really what help us promote health and well-being that's sustainable for patients and families. So this all sounds pretty good. But it's important to talk about how we operationalize this day. The structure of our program is that we're an eight-hour a day, five-day a week, day treatment program, which is very intentionally structured to be able to optimally partner with families when kids are with us during the day, often having family meetings as well, and at home in their home environment in the evenings and on the weekends.
We have two milieus. One is a younger child milieu, ages six to 12, and the older kids are 13 to 18. Our median length of stay is 18 to 20 days. And approximately, we have 190 admissions per year. However, in early 2015, our program is slated to expand. And we will be increasing our census by about 50 percent in order to meet the demand that exists throughout our region. It's important to think about who is it that comes to our program. Because it is important that patients that come have both medical illness or presentation, as well as a psychiatric condition that's playing a role and that's interfering with a patient's functioning.
These patients must be stable enough to be at home. They can't require a 24 hour inpatient care setting from either a medical or psychiatric perspective. They may be patients who are being discharged from the inpatient setting and at high risk for readmission, patients who are being treated in the outpatient setting with functional impairments that have been refractory to outpatient treatment, or patients who are being treated outpatient and are at high risk for inpatient admission due to either psychiatric or medical compromise, or both, and are in need of more intensive treatment to prevent readmission.
Our program is unique in that we partner with patients and families with a variety of presentations and diagnoses. And we do it all within the state model. Our overarching approach is universal, regardless of the illness presentation or the challenges. We're commonly caring for patients that have diabetes, inflammatory bowel disease or other chronic illness, patients with eating disorders, and somatoform disorders. And some of the common challenges that we see are disordered eating, medical non-adherence, functional syndromes, school challenges and avoidance, coping issues, or medical child abuse.
We have a rich multidisciplinary team focused around supporting kids and their families with nutritional, psychological, social, and educational challenges. And as I mentioned, the patient and the family really are at the center of this team. It's also really important to talk about the outpatient providers, who are the folks that the patient and family have chosen to partner with them on their journey longitudinally. And they are really, really valuable resources in providing history and perspective, as well as identifying treatment goals with the family in establishing follow up care. It's essential that patients and families understand that we value the input of their identified providers, and that we really are going to work together with them. And in doing so, we strengthen our partnership and support more positive shifts throughout the course of a patient's admission and beyond.
MICHELLE RICKERBY: Thanks, Diane. I'm going to go on and share a little bit more detail about our perspectives for supporting families in integrated care, and focus on what families experience during their stay with us. This is a simple pictorial of what's a complicated process of our effort at supporting families. And one important thing to note is that families and patients are always at the center of our efforts.
Part of what hopefully comes across in this diagram, too, is we're creating a ring of safety around them during a very vulnerable time in their lives. Our efforts aim at, of course, supporting a productive supportive relationship between our treatment team and the families, as well as supporting productive connections between family members and with families and their larger treatment network, including outpatient providers and schools.
So as Diane noted, we meet families where they are. And one of the ways we do that is in helping them understand the illness that they're dealing with in their child. And it's not just understanding the illness entity itself, but placing that illness in the context of their child and family's life very specifically. Often, when patients and families are entering our program, they're feeling quite hopeless and helpless in terms of being able to manage the illnesses. In looking at the illness broadly, we assess the impact of it on family relationships, and also, of course, look at the family more broadly, looking at preexisting challenges that may have been there that also present a barrier to effective care.
One way of looking at this is identifying an opportunity amidst a crisis to look at the bigger picture and support healthy family functioning. We make every decision in our program, both small and large decisions, from a family-based perspective. And this does not simply mean involving the family, but very actively engaging the immediate family and often extended family in the process.
Of course, family therapy is a central piece of treatment that families are involved with during their stay. But family-based treatment goes beyond that. We understand that the family and patients are the experts in their own experience and make every perspective, or every decision from the perspective that the family's understanding of the illness as well as family relationships are a powerful force in illness management and recovery.
When we speak about integrated care, we're not simply talking about the concept of integrating physical and psychological issues, although of course that's something we do. We really look at putting all the puzzle pieces together, which may be a quite complicated process. It's very common that parents will say, after their children are with us for some period of time, “I'm so thankful that you're looking at my whole child”. Part of how we do this is by integrating the messages we're giving patients and families about empowerment across all the pieces of care that they're getting, from pediatric care to psychotherapy to case management to psychopharm interventions.
Some of the experience that families have during their stay involves daily nurse support and education. One of the very important pieces of the day is our check in and checkout process at the end of the day, when families hand over the care of their children to us through our pediatric nurses. Both the beginning and the end of the day communications really allow us to reinforce treatment messages and reinforce the fact that they have a safety net with us while we're working with them.
Pediatric monitoring and treatment is a very integral part of the program, which occurs throughout the course of the whole day. Another example of a family experience might involve nursing or nutrition education about their child's illness. We have family support groups focused on both allowing parents to share their experiences in a complicated process of supporting their children and also on educating parents around some of the skills that we're teaching their kids to address their illnesses.
I often start the family support group each week by saying to the families that one of the reasons we have the support group is to acknowledge the reality that family relationships are the most important force in both illness recovery and long term illness management. Other experiences that families have, as I mentioned, include parent training with some of our specific skill building curriculum with the children. One of the important pieces that we work on with the kids is that oftentimes, they're so overwhelmed that in isolation they can't employ skill building techniques. So we work with the kids on knowing when they need to ask for help versus where they can manage independently.
Family therapy is very important and central to our program. Close collaboration, not only with the other providers treating the identified patient, but also collaboration with family health care providers, including parents and siblings is an important part of what we do as well, to have the broader picture. We spend a lot of time supporting family members (most notably parents, but often siblings as well) in caring for themselves and we actively support parents seeking referrals as needed for themselves.
So the good news of working with some very high intensity challenges with complicated pediatric illness are that we know that a trusting partnership with patients and families is absolutely critical to patient outcomes. We acknowledge that if we know where we are starting with a family in terms of their beliefs about the illness and how they're connected around it, no matter where they are to begin with, we know what to do to support them moving forward. We understand that consistent messages across providers definitely matter and are very powerful in helping families feel empowered, that excellent provider collaboration is a very strong force in supporting patient and family success, and also that any painful challenge, or symptom, or illness is improved set of beliefs and empathic relationship surrounding it.
So I'll end on a note from a patient that really highlights the fact that often amidst what may be an overwhelming crisis, there really lies tremendous opportunity for people to move toward health and well-being. “The Partial Hospital Program was the best thing that ever happened to me. It changed my life.”
BEV JOHNSON: Well, Diane and Michelle, very compelling description of your wonderful program. I'm sure that the listeners today will have some questions for you. And let's take a few moments to explore what some of those are. We do have a question that is talking about working with foster children and dealing with some of the instability that's often in their lives. You know, have you worked with these children, and how have you supported them when they may– placements may change frequently.
MICHELLE RICKERBY: Absolutely. I think that's an excellent question, because we know this is a very vulnerable, at-risk population to begin with. And our program has experience actually in working with children in various phases of the foster care system. Examples might include actually children where we may be working both with their family as well as with the parents they're placed with in foster care, including over the trajectory of reunification. We also may foster families directly, even when the biological families are not involved. And our model applies just the same.
One very special example of working with kids in child protective custody include patients who are in group homes. And although that's not a common experience that we have in our program, we have accommodated that over the years and partner with the group homes the way that we would with families and work with staff to support the kids' needs.
BEV JOHNSON: That's terrific. Thank you. There's several questions about traumatic head injury. And probably you have worked with children and families with that condition and one of the questions, part of it, is on helping families understand the complexity of recovery. And I think there's lots of misunderstanding about the progress. And then have you found community local support? Any examples of exceptional care from education?
MICHELLE RICKERBY: Yes. Let me try to answer that question and Diane can add, as well. We do have definitely a fair amount of experience working with kids with a range of traumatic head injuries. And it is a very complex process, and a good example of one where often the messages families have received about the trajectory of recovery can be very confusing, partly because it can be so unpredictable. It's also a really good example that sometimes there's been over attention to some of the physical and neurocognitive aspects of recovery, but that there's a neglect of looking at how emotionally upsetting it is to the kids, and demoralizing, and also the pattern of fear that can develop about moving forward with their lives.
So we are able in our environment to support all aspects of that care. And we work very closely with outpatient providers, neurologists, et cetera, and school systems on providing a realistic set of goals for when kids leave. There are situations where parents and families sometimes are underestimating the deficits kids have, and other times where they may be overestimating the symptoms the kids have and, therefore, by supporting the kids avoiding moving forward. And in our environment, because we spend the days with the children, we really can clarify what's a realistic goal.
BEV JOHNSON: Great. Thank you. There's a question from Cincinnati about the children and families you're serving, that they're truly experiencing patient- and family-centered practice. What are you doing to prepare the youth and families to transition to an adult health care system? I must say, I have to comment that we have work to do. And we know we do. But we need to make sure that the adult health care system is as patient and family-centered as pediatrics, particularly as you all have described it today.
DIANE DERMADEROSIAN: Really, really good questions. I think in terms of addressing the question of whether or not we are providing patient- and family-centered care, we believe we are. And everything that we do is reflecting that. In terms of transitioning patients to the adult care setting, we know that in so many systems, that is a challenge. We here at Hasbro have a program called the Adolescent Leadership Council, which is a unique program where patients with chronic illness participate and have mentors who also have chronic illness themselves, but who are in college and who have actually already transitioned to the adult health care services in our state.
And there are also medical students, and residents, and other folks who are part of that program. And there has been a lot of initiative for us to work with the individual offices, the endocrinologist, the cardiologist, pulmonologist, all the groups that are receiving a lot patients with chronic illness that are transitioning from pediatric to adult care to support a smoother transition.
MICHELLE RICKERBY: The other piece I would add is yet another example of where among 18, 19, 20-year-olds, there's a huge variability in realistically what they may be able to take on in terms of their illness management. And again, sometimes the kids and the families may be either overestimating or underestimating. Our environment is really good for hashing that out in the older teenagers, and again trying to set realistic goals and expectations and assisting outpatient providers with that as well.
BEV JOHNSON: I think you've described a wonderful way that you're beginning to focus on that critical issue of transition, individualizing it for the individual patient and family, but also trying to build the system. And the fact that you have an Adolescent Leadership Council influencing, trying to build the adult system so it is as good as what you all have done in pediatrics. But I love the fact that in an academic medical center, you're exposing trainees and faculty to thinking about these important issues of transition. So thank you to the work you all are doing. And thank you to Paul for your thoughtful question.
There's a question also about whether the team of physicians actually meets with the family, or do you serve as the intermediary? What does that kind of look like in your program?
MICHELLE RICKERBY: Yeah, there's actually multiple. As you can tell from our presentation, there's a whole range of meetings families have while they're here. We have primary therapists who are the core bridge to the families who are doing family therapy, and a lot of the meetings. But in addition to that, we have a lot of meetings involving other members of our team. So for example, the psychologist, psychiatrist, pediatrician, and maybe one of the nurses may join a meeting at a particularly difficult juncture for a patient to clarify the medical plan.
And in addition to that, it's very common here that we might put together a multi-provider meeting that includes maybe up to 20 people to support a child. That might include members of the extended family, multiple outpatient providers, including primary care docs, sub specialists, folks from school, mental health providers. That's often something we do around the time kids are transitioning out of our program.
BEV JOHNSON: Michelle, and thank you for that, Michelle and Diane, you know, throughout your presentation, you talked about the importance of teams. And I really think it's certainly exemplary in terms of reflecting patient- and family-centered concepts that patients and families are on the team. All the different disciplines are on the team, and people in the community. It feels like you're all working together. What advice would you have for others starting a program either like this or a similar program to get that understanding of team, where all of those players– often we describe team as an interdisciplinary team, but it misses the involvement of patients and families or people from the community.
MICHELLE RICKERBY: Yeah, I think there's a couple of key pieces of advice. One thing that we didn't highlight in the talk was our process of multidisciplinary team rounds, which we have four days a week with our entire multidisciplinary primary team, during which we talk about every patient in the program. So I think the process of setting up an effective version of team rounds is really, really important.
The other piece of information or advice I would have about that is conflict is normal. Disagreements come up. And we try to normalize that process in families, also amongst our team. And we know that if our team is not functioning as a healthy family in terms of everyone having a voice and coming to collaborative decisions, that we're not going to be able to support the families doing that as well. So we put a lot of support into our team and helping people with that process.
BEV JOHNSON: Great. Thank you so much. And just thank you for all the wonderful work you're doing. And I know that there are many people on this call today who have been inspired. And I think what's exciting is while Diane and Michelle have described this innovative program for children and youth and their families, many of the core concepts we can apply to building patient- and family-centered systems of care for seniors.
And whether we're talking about in the ambulatory care, really we're not caring for an older patient alone in isolation, but that we reach out and find out who is the support person. This older gentleman has early stage dementia. And his wife is critical to keeping him home and functioning as well as possible. She needs useful information. She needs support and the connection to feel that she is really part of the team. And you can kind of see the dynamics in this picture of they're all working together and that she does feel part of that team.
And then building on what Diane and Michelle said about the rounds and fostering the teamness, the clinical rounds, the teaching rounds, inpatient– here you see at The Christ Hospital in Cincinnati a very collaborative team that is conducting rounds at the bedside with the patient. In this particular case, the family wasn't there that day. But the family is encouraged and supported in being part of the rounding team, which is really a safety strategy and a strategy to ensure the best transitions from the hospital to home and community care. This academic rounds program was funded by AHRQ as a research study. And patients– older adults and their families– were part of shaping this research. They're already beginning to get some very interesting data about reduction in falls when rounds are conducted this way. And both the older patient and the family feel like they're really part of the process and are part of the process.
It's important to think about, in the care of seniors, that hospitals can be particularly stressful. I think they're stressful for probably just about any patient. But they're unusually vulnerable, older people, are and we know that social isolation is a risk factor. So it's important that we look at what our policies and practices are. Because often what happens is we isolate patients at their most vulnerable times from the people who know them best. And that puts them at risk for harm and costly unnecessary care.
We also know that for many older adults, that hospitalization, either in an ICU or in a med surg unit, can be associated with reduced cognitive function. And families and other care partners, however, with a broad definition of family, they may be more aware of any change in cognitive function before staff recognize it. Because they know the patient so well, they pick up these subtle changes. And so to think about it, we need to go beyond thinking of families and other care partners as visitors, but really thinking of them as allies for quality and safety.
There's a wonderful report that was written several years ago. But it certainly is relevant today. And Lucian Leape, Don Berwick, Carolyn Clancy, Jim Conway, and others authored this article about “Transforming Health Care, a Safety Imperative.” It was published in the BMJ. It's a very short article. And you could download it and discuss it within your organization. But one of the key points they make in this article is the family is respected as part of the care team, never as visitors, in every area of the hospital, including the emergency department and the intensive care unit.
And I think that has so much relevance for our discussion today. There is no evidence that having restricted visiting hours, of arbitrarily through policy restricting the access of the patient to their loved ones. And sadly, we've not been able to change that culture and those policies and practices in many hospitals. So that earlier this summer, the Institute for Patient- and Family-Centered Care launched a campaign called Better Together, Partnering with Families, with a goal to eliminate restricted visiting policies in a thousands of hospitals across the country by 2017.
And we don't want people to just take down signs. We want people to collaborate with families and other care partners as essential members of the care team, according to the patient's preference. So I hope you will find the resources developed for that campaign useful. And I'll share more information later. But really, in building this culture change to support these kind of innovative programs that you heard about at Hasbro, and you're going to hear about at Holy Cross, you really need leadership commitment to build a patient- and family-centered system of care.
And in Atlanta, at the Emory Health System, they embedded advancing the practice of patient- and family-centered care in their strategic plan, so that their leadership will give it deliberate attention and it will move forward. And they put specific measures of what they wanted to change. And they were going to partner with patients and families and really make changes in the care delivery system and care processes.
And once they did that with, particularly nurse change of shift, they were able to see over a two year period tremendous improvement, a 40 percentage points improvement in overall nursing care and how well pain was controlled. And it was that partnership with front line nurses to change that care practice that drove that kind of outcome. They also were very involved in the planning a facility that is serving a large number of older adults, an orthopedic and spine hospital. And patients and families served by this hospital were critical to the planning of that hospital.
Since the doors opened, they haven't been below the 96th percentile in patient satisfaction in the last six years. And the patient and family advisers, they certainly were involved in the design of facilities, but they were part of looking at the care processes, whether it was rounds, change of shift, how you were admitted, how you are discharged. They helped develop all of those. And they're able to show that their length of stay is one day shorter than other specialty hospitals that they are benchmarked with. And what is exciting to see, patients and families were involved at the beginning. And they still are involved today.
I wanted to give one last example about emergency care, because we're going to hear about how an innovative hospital transformed emergency care for seniors. Contra Costa Regional Medical Center is a public hospital in northern California, serving a very diverse community. And their hospital, like I bet many of your hospitals on the call today, had problems with flow in the emergency room. And they partner with patients and families to get these amazing results in the emergency department. And again, it's a partnership with the community, staff across disciplines, and the people served.
So thinking about this possibility to bring about change in emergency departments, I think you will enjoy hearing about the innovative work from Holy Cross Hospital and their seniors emergency department. With us today is Judith Rogers. She's president of Holy Cross Hospital in Silver Spring, Maryland. And she has served in that role since 2003.
But what I think is wonderful, they clearly like her there and have such tremendous respect for her. And she served in a variety of different roles over the years, as Senior Vice President of Operations, Vice President for Women and Children Services, Chief Nursing Officer, and Vice President for Patient Care Services. So I know you will enjoy learning from Judith. But first, you get to hear her video. And then you will get to talk with her directly. Thank you.
-Mary presented for an acute episode of required care for her diabetes complications. She was first screened for her age, found to be 75. That made her eligible for the seniors ED. The seniors ED started with a focus on how do you maximize the family's contribution. So what's important to you as a family member. So we craft the whole plan of care around how we're advised. We committed to changing practice. As we attempted to render services to Mary, all she kept saying to us is, I have to go home. I have to go home.
-In the process of intake, we queried where Mary was in her life phase. That story revealed that Mary was the primary caregiver of her husband who had Alzheimer's and who was home alone. No one was changing Mary's mind. And she was leaving. Because to her, no matter what, getting home to her husband was the priority. To care for Mary is to care for something larger. And we truly really believed that in order to treat Mary, we had a treat her husband, even if it were to just admit him along with Mary until we could figure out the next step.
And while he was there with us, we evaluated his Alzheimer's. We treated Mary. We admitted her too. The role of the family in follow up care, with transitional care, or inclusion in service provisioning, that's such an important part of what we do and where we learn that the absence of family or someone there to work with us really made us up our game. Our geriatric nurse practitioner began to make phone calls. It took a lot of digging to unearth that Mary had a remote niece.
-Even though she couldn't come, she did, in her mind, still want to be part of what we were doing. We make that easy. We'll show you exactly what your next steps need to be. We'll hold your hand. We were able to discharge Mary stable, with a follow up appointment with our primary care physician. And we were able to arrange for in home services ongoing for her husband.
-But the best part story was we kept track of both Mary and her husband for weeks. It was almost if we became the conduit of engagement. Hi, it's Holy Cross. Hi, we're just calling to let you know. Hi, do you have any questions for us? One person answers the calls. One person knows what's happening. And one person interfaces with the family with the sincerity, authenticity, genuineness that we really feel about our responsibility to care for seniors.
-My name is Judith Rogers. And I believe to be an expert in the care of seniors is to partner with families in the care of their loved ones.
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JUDITH ROGERS: Hi. Thank you. It's just my pleasure to speak with you a little bit about Holy Cross Hospital and our Seniors Emergency Department. A little bit about us. We are a full service acute care facility located in the Washington, DC area, founded in 1963 by the Sisters of the Holy Cross, so there's a 50-year legacy with our community. And as you'll see in a minute, the Seniors Emergency Department initiative is clearly a reflection of our understanding of what and how we might best serve those that trust us to do so.
We have a large medical staff, greater than 1,000 members. And all in, we have greater than 400 beds. We do about 9,000 deliveries a year, so we have a very large obstetrical presence. And for a long time, we viewed ourselves primarily through that lens of being an obstetrical service. Clearly, the demographics as we came to better understand them, told us that we needed to be a bit more involved in the care of our seniors. We are the only teaching hospital for medical education in Montgomery County. We see revenue of greater than $300 million. And we remain very delighted with the amount of community benefit that our acute care service activities permit us to turn right back into those in our neighborhood.
We have a robust, both inpatient and outpatient, acute environment but really, in addition to OB, that which bustles is our emergency department. The vast majority of our admissions as well as our outpatient visits take place through our emergency service department, exceeding greater than 90,000 visits annually. We have a very robust workforce, greater than 3,000 staff members.
We are a minority majority environment, in that the majority of our workforce is non-Caucasian and made up by individuals of more than 100 different countries. In fact, we often will query the number of languages spoken by the staff, and it always exceeds 100. We are honored to have received the Workplace Excellence Award for the last 14 consecutive years, and especially in a period of time of great change in the health care industry to have a very stable workforce with no layoffs in the last decade.
I mentioned our diversity, both in our staff, but it's worth a comment about the diversity both culturally and ethnically within the population that we serve. You can see the distribution in a slide here. But what's most important to the conversation is the overwhelming dominance of the senior population in our local community. It far exceeds the national average presently and does so as we look forward to how the population will be distributed by 2018. We will see projected increases up to 23 percent of seniors in our local market by 2018, compared to only a 2 percent growth in that same market of all age groups, 0 to 64. So in this commitment to serve the community, it was clear to us that something really needed to be done very special for our senior population.
But in referencing Bev's comments about how it all starts with leadership, the story of our Seniors Emergency Department indeed started when our CEO had his mom hospitalized in New Jersey. So here in Maryland, he's on the phone constantly trying to better understand what's happening, how he can be of service to those caring for her, that he can understand what really has brought her to the emergency department, and what might then be the plan of care going forward. And he found the situation overwhelmingly frustrating, just overwhelmingly frustrating.
He never spoke to the same person twice. And he really couldn't offer his mom the support that he wanted to until such a time as he could get there. And so the core purpose focus of our decision to create an emergency department specifically for individuals greater than 65 years old was to focus on improving patient care, improving the patient's experience, what they actually had to say about how they viewed their perspective of care, to engage the staff towards improving satisfaction, and to create greater workplace satisfaction for them, to look at the resources we were currently allocating to those who served in our emergency department, making certain our senior population received a sufficient resource allocation.
We wanted to reduce our readmission rates, reduce our complication rates, look at our length of stay, and take a look at about how we were actually being reimbursed and this whole issue of value-based reimbursement, how it would change were we to see ambulatory sensitive care being delivered in the emergency department and not where it belonged. Or if we were not respectfully attentive to possibly preventable complications with all of the implication of how that would alter our reimbursements.
We looked not only to what we needed to do to optimize inpatient services for our seniors, but also to bridge or connect with what we appreciated to be a sizable amount of outpatient and community health resources in our community health arm of our health system. We had not to date successfully done that. So this endeavor was really to say, we've got a lot to offer on the acute care side. How can we best then make certain that the transitions of care from the inpatient side to the patient's return to either their home, or their SNF, or their nursing home, how can we optimize that so that resources don't just abruptly stop, but so there can actually be an ease of transition into the next phase of requirement?
We wanted to establish effective and expedient means for that to happen. And we wanted to also prepare for the fact that we know, we can predict the prevalence of functional decline, increased dependency, and increased morbidity when seniors with certain criteria experience an acute care episode. So in knowing that this is likely to happen or that the senior is vulnerable to this happening, it becomes then the task of the acute care environment to say, “all right, how do we engage the family to plan for this probability?”
How do we look at these transitions, such that we don't assume that the senior can go right back to where they came from? Because if indeed there has been a functional decline or a shift in the senior's ability to care for self, what can we get ready in anticipation of the potential where this might potentially happen. And how can we engage the family in readying for this possibility?
We also wanted to make certain that the environment of service delivery, both in our Seniors ED as well within all of our senior programs, acknowledge that over and above all else, safety for the seniors must come first. So our Seniors ED, for example, we keep the temperature quite warm in there. In fact, that is a criterion. The staff must like tropics when they work in there. We have thick mattresses to be certain that the senior is most comfortable– low lights, large clocks and calendars, all preserving the autonomy, independence, and sensory age-appropriate demands that the senior might present us with, all the while always thinking next steps of readiness for transition.
The family plays a huge role in everything we do. I think the video about our patient, Mary, references how we pay special attention to inclusion. We know that respect and dignity, both for the family and what they're going through as a result of the senior's inpatient or acute episode, as well for the patient themselves. We know that information is key. Going back to our health system CEO's experience, the primary frustration is, I don't know what's happening, and the horrible sense of being insufficiently able to support his mom in the experience that he found her in.
So we know that making certain we have hard-wired systems for inclusion of information for the senior as well for their family is very important. We know that the family's engagement in devising the plan of care and making decisions that are essential to the plan of care are critical. And as Bev already said, the approach to this, is that it's not a second thought or “oh yeah, I forgot to include the family”, but it is actually to approach family members as essential participants- allies- in the work that we're doing.
You know, that took a bit to convince the staff that slowing things down to make certain that the degree of inclusion was achieved was of value. Because it wasn't that they wouldn't have wanted to do that, but that showing how important that became in making certain that the senior was appropriately cared for actually made their job easier over time. And that became evident as call bills were reduced and as the seniors were better supported during their stay, as exemplified in our Seniors ED.
That drove home to the staff by just their own observation of what the payoff was, not only for the plan of care but for their own experience in wanting to do best for these patients. And we also knew that hard wiring this constancy of support systems was going to be very important.
As we begin to work with the staff in their understanding of why we placed such value on family engagement, our position was simple. We learn from the family. This was not just a one way street of “oh, yeah, make certain the family is informed”. But rather it was, “stay quiet and listen, and ask the right questions” so that your understanding and your ability to treat, especially in the Seniors ED, and in a short time frame, is informed and advised by the information and unique understanding that the family can share about their loved one with us.
We know too, that our ability to expedite discharge and to be confident that the patient and the senior will continue to be well cared for is that we transition this ownership or stewardship of service to the family prior to the patient leaving. And without a doubt, we were able to show our staff that better outcomes are clearly supported by greater family engagement. They began to see how much better seniors fared by function of the follow up we then are able to conduct later on that had not been present before.
As you know, the video I think well illustrated this: to care for Mary, as exemplified by that discussion, was to care for something larger. There was just no caring for Mary if we weren't going to find out, figure out, a way that we could care for her husband or relieve her of that burden of feeling that she could not self-care until her other responsibilities were addressed.
That example and many others show us that when the family is not present or involved in care, or the senior feels an obligation as the family' caretaker, it really is more difficult for us to provide optimum acute care services. There is questionable follow up. And the transitions of care are challenged. And so when we worked with the staff about being certain of why the family was so important, these truths became very important in their training and in hard wiring how our processes work here about who is actually involved in the care of the senior.
We ensured that in addition to making certain that the environment of the Seniors Emergency Department was optimum in managing age related issues that challenge seniors, we made certain that our infrastructures of continued support were sustainable. Not only that the partnership with the loved ones of seniors is important, but we wanted to make certain that we established a one person interface here at the hospital where when families went home, there was one single individual that they could call back to and say “you know, I just got home with my mother, my grandmother, my aunt, and I'm confused”. Or “I'm having difficulty connecting with a resource”. Or “you know, I thought I understood what you explained to me as part of the discharge information, but I'm not so certain I do now”. We wanted also that person to be one that had an ease of communicating sincerity, authenticity, and genuineness, so that the family would be sure to stay contacted with us should other issues arise down the road. And we could direct them to the next service opportunity.
Keeping the staff engaged was quite a challenge for us at the beginning. You can only imagine walking into an emergency department seeing 90,000 visits a year and tell those nurses to slow down a bit. They were like, “Whoa, we think that's impossible”. But we reminded them of the mission that we really need to be the most trusted provider in the community. And in doing that, we need to honor that the seniors presented to us with unique requirements that included the inclusion of family and it just had to happen.
We also showed them how we had been successful throughout the rest of the acute care environment. We had partnered with the Erickson School for an all-leader engagement to show us how to truly engage the leadership, who then could select and support the staff in the front line ownership of executing the priorities of all of our programs.
We have an ACE unit, or Acute Care of Elders unit in our inpatient side of the house that includes multidisciplinary rounding three times per week for all patients included in the program. You see they reference the Senior ED. You also see our seniors ambulatory surgery department, our caregivers support group, our Geriatric Resource Nurse Council. All of them have, as a focus, how the family can be included in the services that we deliver.
Selecting the leadership for our emergency department was critical. We needed someone with a significant background in emergency service delivery, but also someone who was savvy in the care and importance of geriatric care. The staff, they just need to want to be there. They need to embrace geriatric care. They're screened carefully for that. And they're also trained.
We have– and probably most pivotal roles in our Seniors Emergency Department– are our nurse practitioner and social worker. Those are the two points of constant contact for those that are sent– patients, seniors, that are sent home who then call back and want to be stewarded through the next phase of their care. All of our staff clinicians in the emergency department must complete the Geriatric Emergency Nurse Education Program by the ENA.
And about 75 nurses throughout the house have also completed the NICHE program, or Nurses Improving Care to Health System Elders. We thought that was vital. Our commitment to the staff was we would provide them the education they needed to be effective in the multiple seniors programs. That proved valuable past our own assumption and keeps the staff very engaged in the work that we're trying to do for seniors and their families.
I've already mentioned the importance of follow up. All of our seniors that are discharged from the emergency department or any of our programs, be it the ACE unit or ambulatory surgery department, each of these programs have a contact person that the family is advised to follow up with, should there be any questions. We make follow up phone calls, though ourselves, just to check in to be certain that, as you saw in the video, that all is well and going according to plan.
We are determined to help seniors and their families follow up with a primary care physician, other future services when required, and family support. We often find pending the severity of the acute episode, families get fatigued in their commitment to some of what clearly needs to continue. And we then hook them up with respite care. Or we hook them up with support groups.
But we make it clear through this authenticity of these dialogues that happen between our social workers and nurse practitioners, that we're here for the senior member who sought care or needed care from us. But we're also here for the family, no easy task in the role that they play.
And we make purposeful efforts to let them know we know what a challenge that is for them. We also are committed to polypharmacy review while patients are here in any one of our program, as well as to go over medication management with the families, knowing full well that a large part of compliance becomes a burden or the responsibility of a family member.
All in all, we think that it's quite a robust program that the feedback from our staff as well from our patients, is very positive. And we're very, we're just delighted to have been the first hospital in the country to have done something like this. And we remain committed to keeping it robust and serving the community. Thank you.
BEV JOHNSON: Thank you, Judith, for a wonderful presentation. Thank you for the really amazing pioneer work that Holy Cross is doing in building both the innovative program for seniors in the emergency department, but really bringing this focus to all the work that you do in your hospital to make sure that the hospital is responsive to the special needs of seniors and their families. With a mom who just celebrated a 101st birthday, I'm particularly grateful. I wished she lived in Silver Spring, Maryland and not in Florida to be able to use the wonderful care that you all are providing.
One of the situations that I'm sure you all have dealt with is that often families have complex needs. And sometimes elders are in vulnerable situations. There may be cases involving abuse or allegation that there is abuse of the elder. How are you dealing with that in your emergency departments? Is there something you could share with the group about how you're ensuring safety with great respect for families, but also assuring the safety of the older person?
JUDITH ROGERS: Yes, certainly. You know, I mentioned before that one of our biggest learnings from this program was the responsibility we have as an acute facility to streamline our interface with our community resources, whether they are ours, or outpatient social workers, or our community health workers, or the county. Living in Montgomery County, there's an incredibly robust platform of programs, whether it's senior abuse protection, or it's elderly services.
And we really had been naive to some of what was out there. And so one of the functions of the staff is if we suspect, or are worried, or have any of the signals that we may need to get others involved, we now are very adept at saying “whoops, we're going to turn this over to- and fill in the blank”, whether it's our elder abuse protective services in the county, or whatever the need may be.
So it's really knowing, 1) recognizing that there's a requirement, and that's part of this assessment done by our social workers and nurse practitioners, and 2) in real time, in the moment prior to discharge, connecting either with an intervention at that time, or making certain there's a follow up after discharge.
BEV JOHNSON: Thank you for answering that question. And I'm wondering in terms of– we had questions for the team from Hasbro, as well, to think about how these programs are financed. And I'm curious in terms of the startup for your emergency program, did you seek outside funding? And then what about ongoing financing of the program?
JUDITH ROGERS: You know, thanks for that question. Because many people ask us “how hard was it?” It was the easiest part, because it doesn't cost a lot. It is a very– when you look at the elements of the program, it's really just a decision of what we focus on as. And it's a process commitment.
We had to start up, in terms of the environment of care though, we had the space. So it was outfitting the space with the lighting and the flooring. And we had a $100,000 grant that we used for that purpose. But that was a single, one time investment.
The ongoing staffing really is now just hardwired into the budget. And if you look at the commitment of how much staff per patient, it's not that much different than the acute side, the more acute side of the ED, with the exception of the investment in some of the support roles, such as nurse practitioner and social worker. And we have a coordinator. But that is nominal compared to what we think is the payoff, which is the improved outcomes and the likelihood of fewer readmissions and complications. So that's how we did it.
BEV JOHNSON: That's very helpful. There's another question from a patient advocacy individual that, how did the hospital justify the cost of the husband's admission for the purpose of insurance coverage?
JUDITH ROGERS: Oh, we got lucky there. I probably can't remember what the clinical indication was, and I realized in the video that was a piece that– and thank you for picking that up, because I wish I'd mentioned that he was found when we sent someone out to the home to have a clinical indication for admission as well. So it was not a social admission. He, I don't remember whether it was his hypertension out of control or whether it was CHF, but it was something that clearly was– I want to say “justifiable”, but that sounds fabricated– but it was warranted.
BEV JOHNSON: Great. Another question is about tools and technologies to facilitate this coordination of care between the family, the other caregivers, and the whole rest of the health care team. You mentioned that was used to facilitate conversations. But was there any other health information technology or technology?
JUDITH ROGERS: Yes. Since that video– and my answer was going to be yes, but since the video was shot, which actually impressed me with how fast technology moves, [LAUGHTER] you know. But since that time, we actually have a patient portal. So all patients at the time of admission now are requested. They have an option, but they're requested to provide us their email, or email of a loved one.
And we can actually then arrange for them to go right into their electronic medical record. Now that provides ease of data. But the actual discussion that happens remains just phone conversation. But sharing of the pertinent health information is now done through a patient access portal.
BEV JOHNSON: That's interesting. It's great to hear that evolution just in a short period of time. I'm wondering, there was a question related to the use of technology in helping the program at Hasbro. Diane and Michelle, they wondered whether you all were using technology in similar ways to keep children, youth, and families involved and foster the coordination.
MICHELLE RICKERBY: Yes, we're exploring various options in terms of that. One very interesting area with our population that we've recently expanded on technology is in working with kids with various versions of chronic pain and the use of biofeedback, including investment in some new biofeedback equipment, and handheld monitors, and things like that that have been very interesting to pilot.
DIANE DERMARDEROSIAN: And in addition, we're hopeful that at some point in the future, we'll be able to utilize the GetWellNetwork, a modified version within our setting as well to support some of those same goals.
BEV JOHNSON: Wonderful. Great. Well, thank you very much to all of you, Judith, and Diane, and Michelle for sharing your experience and your insights about this wonderful work. I wanted to just share with you other resources that might help the audience today move forward with advancing the practice of patient care in specific populations or across all ages.
There are a number of tools at the IPFCC Web site. There is a brand new– we are featuring this month a new report from the Macy Foundation about interprofessional education and how to partner with patients, families, and communities. Here is the BetterTogether Web site, which is a part of the IPFCC Web site with videos, and tools, and many resources that you could use to change the concept of families as visitors.
Here are some of the references that I cited when we talked about, particularly talked about, caring for older adults and how it's so important that we need to change the concept of families as visitors. And there's some very interesting articles by a security chief at the University of Michigan linking patient and family center practice with security.
And AHRQ has a number of wonderful resources that are available on its Web site and a terrific kind of guide for patient and family engagement to enhance quality and safety in hospitals. And there are a number of tools also in the Patient Centered Medical Home Resource Center.
So I hope that you'll be inspired by the thoughtful conversation today and you'll want to tap into these resources. And I'd like to now turn it over to Judi.
JUDI CONSALVO: Thank you, thank you. This has been an amazing conversation from two wonderful innovators that occurred in our process. So I thank you so much to our moderator, our presenters, and especially to our audience. And as Bev just mentioned, there's a variety of resources available to you. So we hope that you do explore those.
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