Teamwork Leads to Patient Successes
“We have a big team, but I'm constantly in communication with everyone to make sure we all stay on the same page.” --Shelley Goldman
Whether a patient comes from the Tri-state or the UAE, Cincinnati Children’s staff always practices the core tenant of care management: Working together to give compassionate care to patients in order to provide the best chance for positive outcomes.
Our Care Management team uses a multidisciplinary approach to address non-medical factors that nonetheless impact patient health. Care managers make sure testing and follow-ups are completed while also helping families avoid scheduling issues. They also build trust with families and coordinate with medical teams to address other challenges outside the clinical realm.
“We work with medical staff, but care managers play a unique role,” said Diane Herzog, MSN, MBA, clinical director, Care Management. “Our expertise is in the coordination of care so that patients can have everything they need to be successful at home.”
Comprehensive Care Means Looking for Clues
Care Management teams rely on referring providers and community health workers to notify them when a family needs support. However, some patients experience non-medical challenges that impact their health but occur away from the hospital or outside of the reach of care providers. So, care managers look for outliers that might indicate a family’s need for help. High admissions numbers provide clues that a patient might benefit from a multidisciplinary care approach.
“We had one patient who had several dozen emergency psychiatric admissions over a very short time frame,” said Herzog. “Typically, that’s a sign that something beyond the medical diagnosis is affecting a patient’s health.”
Shelley Goldman, care manager, has hour-long conversations with the patient’s mom to understand specific challenges, act as a sounding board, and build trust with the family.
“There are other kids in the home with health issues, and mom and the patient struggle to effectively communicate,” said Goldman. “Plus, the patient struggled to connect with people at school, so attendance was an issue. The patient felt voiceless and alone, which compounded existing mental health challenges.”
Goldman actively participates in a wraparound team consisting of medical providers, community supporters and school staff who have tried unsuccessfully to improve the patient’s situation. Early in the process, she advocated for residential treatment. The patient learned some new communication skills but struggled to put the techniques into practice with mom. So, Goldman assembled a team that would take a comprehensive approach to the patient’s healthcare. This included finding a therapist for mom.
“We tried having in-house sessions to help mom with communication techniques, but we learned that having mom and patient in the same room during sessions didn’t allow everyone to have a voice,” said Goldman. “Instead, we found mom and the patient separate therapists who operated out of the same office. Mom felt a lot more comfortable with this arrangement, and the communication began to improve.”
Goldman also enlisted the services of a new medication provider, home health nurse, a HealthVine social worker, and Applied Behavioral Services.
“We have a big team,” said Goldman. “But I’m constantly in communication with everyone to make sure we all stay on the same page.”
Goldman also worked with mom on an Individual Education Plan to advocate for the patient at school.
“Emergency room visits and inpatient admissions are way down," she said. "The patient loves the new school program and has been attending class regularly and thriving. I even saw a homecoming picture which brought a huge smile to my face.”
“Our expertise is in the coordination of care so that patients can have everything they need to be successful at home.” --Diane Herzog, MSN, MBA
Another Care Management Success Story
A HealthVine care manager reached out to a family whose child had a complex medical history, including congenital CMV and cerebral palsy. The child had begun exhibiting aggressive behaviors, including playing with and pulling out a G-tube, resulting in three ER visits in a 6-month time frame.
The parents became increasingly stressed about G-tube complications. The child was stressed, as well.
The care manager partnered with the Gastroenterology team and came up with a recommendation for a G-tube protective belt. However, the belt was not covered by insurance.
HealthVine used Social Investment Fund money to purchase the belt, which resulted in a reduction of ER visits, which also reduced the cost of care for the family. But even more importantly, the child was spared the stress of having to have the G-tube re-inserted, and the family could breathe easier about complications.
Finding the Best Path
Understanding cultural differences in medical care was a critical factor in helping parents from the United Arab Emirates (UAE) whose newborn needed surgery at Cincinnati Children’s.
The family transferred from a hospital in another state and experienced stress related to lodging and insurance coverage. Their Medicaid application from that state was completed, they did not have insurance from UAE, and they didn't know if they should stay in a hotel, at Ronald McDonald House, or the Newborn Intensive Care Unit (NICU) inpatient room. The parents wanted the best possible care for their child, but they weren’t sure if that was best accomplished here or at home in the UAE. Jean Luchini, Destination Excellence (DE) nurse care manager, Courtney Cassady, NICU nurse care manager, collaborated early on with the rotating members of the NICU medical team to navigate the family’s shifting priorities. The care management team coordinated a care conference to help the parents find a path that worked best for them.
Shortly after the care team developed a tentative plan to discharge the family to Ronald McDonald House, the parents decided they’d rather return to the UAE. Mona Eljouzi, an international specialist, helped with passport challenges and travel logistics and acted as a mediator between the family and the medical team.
“Mona’s role, though non-clinical, was invaluable in assuring that the family and clinicians understood each other’s concerns and perspectives,” said Luchini. “Her cultural expertise was extremely helpful in providing a positive experience for both the family and clinical members of the team.”
Both Eljouzi and Luchini remained flexible during daily changes to the family’s repatriation plans. Collaboration between Cassady and Luchini helped the medical team with the handoff to the pediatric subspecialist in the UAE and making sure the family had any equipment they needed once they returned home.
As a result of the early-stage planning and collaboration between DE, inpatient care managers, and clinical staff, the family was well-prepared, and the parents felt confident with their decision to go home to the UAE and return to Cincinnati Children’s when needed for specialty care.
“Working together with the Destination Excellence team highlighted the compassion, work ethic, and commitment of our teams to change the outcome for a patient and family that went beyond the walls of the hospital,” said Cassady. “I was honored to work so closely with the Destination Excellence team, and in turn, I grew as an inpatient care manager learning more about our international patients and families.”
“Finding solutions for families that are in complicated situations isn’t something someone can do alone,” said Herzog. “Taking a multidisciplinary approach is critical if we want our patients to experience holistic, positive outcomes.”
“Working together with the Destination Excellence team highlighted the compassion, work ethic, and commitment of our teams to change the outcome for a patient and family that went beyond the walls of the hospital.” --Courtney Cassady