Cardiac Nurse Case Management HBDHB

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Cardiac Nurse Case Management HBDHB

• Maureen Bent 19.10.05

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Practice setting

• Heath Care Services is the major public health
  provider in the region comprising
• Hawkes Bay Hospital on the Heretaunga Health
  Village site in Hastings (400 bed capacity)
• Rural health centres in Wairoa and Central
  Hawkes Bay, a city health centre in Napier and
  health services at the Chatham Islands

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Case Coordination in Hawkes Bay DHB

• Presently 9 Case Co-ordinators
• Respiratory/ Cardiac/ Wound/ Urology/ General
  Surgery/ Orthopaedics/Older persons x 2/
  Paediatrics respiratory/ ACC
• All these roles have similarities but are
  designed to meet the needs of the patient group

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Generic referral criteria for all case
coordinators

• Patient having difficulty coming to terms with
  their new condition
• Chronic illness with deteriorating symptoms
  (ongoing planning and management required)
• Patients with multiple variances on clinical
  pathway delaying discharge
• Patients with illness causing social isolation
  not coping either physically or emotionally,
  family dynamics impaired, requiring multiple
  services and planning
• Potential for or actual readmissions with same
  diagnosis

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Background Cardiac CC

• Personal RN with extensive Cardiac experience
• 15 years Ch/N ICU and CCUs
• Post Grad Certs ICU/ CCU
• BN
• ECHO Cardio graphic training USA Australia
• Post Grad Cert Case Management Melbourne
  University
• Post grad Dip Resuscitation Otago University
• Completing Masters Nursing - EIT

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History of the Role

• Commenced Oct 2000. This position was new to the
  organisation
• Cardiac highest admitting diagnosis with several
  readmissions
• Limited resources prior to 2000 (lt4hours rehab
  per week)
• Plan of action setting up cardiac rehab service
• Referral system / Pathways
• Dissemination of information / communication
  across both primary and secondary care

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Philosophy of Cardiac Case Management
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Goal of Cardiac Case Management

• To ensure that the individual patient receives
  the services and resources that he or she needs
  when they are needed

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Aims

• Working with and for the patient
• Enhancing patients access to services
• Actively involve and empower the patients
• Co-ordinate services for consumers by spanning
  organisational boundaries.

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Four Guiding principles of CM

• Empowerment of the patient
• Consumer focus
• Continuity of service
• Single point accountability

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• Case Coordination is about people people as
  clients, case coordination means developing and
  working through relationships with these people
  at a personal level.
• CC do not work with these people in the abstract,
  but rather face to face. This substantially
  demands different skills because of the
  interpersonal skills and tasks required.
• This complexity helps explain why the nature of
  case management is so hard to communicate, and
  can be difficult to grasp at financial level

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• Case management is like a jig saw ensuring that
  all staff slot in for the betterment of the
  patient for timely effective management

Case Manager
Education
Physio
Cardiologist
Patient
Rehab
GP
family
SW
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Cardiac Case Co-ordinator specific Target group

• Worsening symptoms of LVF
• Complicated MI
• Unstable angina medically managed
• Arrhythmias complex
• ICD s or people undergoing CRT
• Three or more admissions in the last 6 months

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• C C works across the continuum of care (breadth
  of role)
• Based on advanced clinical expertise (depth of
  role)
• Requires rapid decision making and autonomy of
  practice
• Has a broad picture (organisational) focus across
  funding streams and management boundaries
• Promoting inter-organisational relations and
  networks
• CC supports and enhances strategic links and
  direction
• Recognises and is part of clinical practice
  structure for nurses
• Advances nursing practice

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Strengths

• Patient satisfaction
• Advocacy
• Decrease in readmissions
• Pivotal person for ensuring care is followed up
  in a timely and appropriate way
• Advanced clinical knowledge required allows for
  credibility across settings and boundaries
• Passionate about cardiac nursing
• Rewarding empowering patients to monitor and
  maintain their own health
• Challenging breaking down boundaries

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Weaknesses

• Volume of clients
• Infra structure in the community not always
  available in a timely fashion
• Some other disciplines find the role threatening
• Frustrating having to justify the benefits over
  and over again
• Who owns the patient !!

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Key Points
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Case Coordinator
Patient
Provider
Funder
Assess Plan Implement Evaluate
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Beautiful Hawkes Bay