Can we talk? A group of providers is improving care for seriously ill elderly patients with a simple solution: Speaking more with one another.
Experts with the Care New England Health System — and several other institutions — laid out their vision Monday in a Health Affairs blog. They describe the use of the “Conversation Nurse” model, which trains providers to discuss serious illnesses and care goals with patients, from hospital to skilled nursing facility and back to their home.
The model has shown promise so far in Rhode Island, decreasing hospital readmissions, increasing hospice consults in SNFs and broadening the skills of clinical team members involved in an accountable care organization. So far, RNs have taken to the effort with enthusiasm.
“We chose to use nurses due to alignment of the project’s goals with the nursing field’s strengths,” the blog authors wrote. “Nursing has a focus on education and communication, and we have found many nurses have a strong interest in these conversations.”
This Conversation Nurse model was developed over a five-year period, using tools from the Institute for Healthcare Improvement. They’ve trained nurses to follow patients from the hospital back to the SNF as a way to reduce readmissions and smooth transitions for individuals with serious illnesses. Nurses are also able to use their know-how from the hospital team, authors wrote, to have ongoing discussions with nursing home residents, and prevent any costly return trips back to an acute-care medical center.
Attempts are now underway to further expand the model into the community and beyond clinical care, authors wrote.