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Presented to: Insert relevant presenter information Calibri 16pt Presented on: Month day, Year Presented by: Insert relevant presenter information here Presented to: Region 7 Collaborative Educational Forum Presented on: February 13, 2015 Presented by: Gwen McNatt, Director Staffing Models in Transplantation
Problem: Pre kidney Growing number of referrals No additional transplants Nurse Engagement Scores falling Nurses burning out, high turnover
Background FTEs (actual) FTEs (budget) TNC (RN/ PA) RN/PA Turnover new pts intervalHQslistedwaitlistDDLDKP/Pcomments visit per FTE transplant per FTE total pts per TNC (lds,new interval, waitlist) Tx per TNC Year2008 9.310.9540%6578087657511179214931 79.2529.25546.0054.4 2009 9.61060%7852081081517116711115833 added RN at mid year103.431.46540.1750.3 2010 10.610.250%8542101122584118714116729 100.331.79674.6067.4 2011 11.31160%9361781195619131313215031 98.5827.70603.6752.1 2012 10.710.5650%8271531146515135211416222 91.5927.85579.6749.6 2013 9.310650%8892101103565140412512331 RIF, leadership change X2118.130.00601.0046.5 2014 9.610667%1070344114842014849813018 volumes projected; leadership change x2147.225.63674.3341.0
Comparison Centers Center referrals per year list size DD tx LD txTotal SPK/Pa nc #RNs#Support on call CommentsOther JHopkins756939136882248/29.87.53 have regular and incompatible teams - 3 person on call/waitlist team plus manager St Barnabas12002000 300082yes also manager/APN who coordinates all KPDs UCLA10002100149122271311155 4 of support team LPNs; 5 person call team Calculate minutes per visit + case followup x # of patients seen x 80% staff productivity in minutes per day determines # FTEs UC Davis1920120029049339289yes post nurse share in call - so 10 total
Proposal PatientsStats/VisitsBenchmarkratio per TNCprojectedneed Staffing Cost (Salary & Benefits) New- LD Recipientsnew visits 1401003303428,366 New-DD Recipientsnew visits 1405006601171,347 Waitlist management/interval visits/kp patients interval visits + KP new and intervals 160 (No Pancreas) 1503803328,847 Living donorsPhase 3 visits NA2003002194,712 NA 91,123,272 Organ Offers (procurement tech) NA 1111,890 Current TNC Staffing 6 Proposed TNC Staffing 9 Variance (3) Procurement Tech for Kidney (1) Total Variance to Current Staffing 4
Results? Difficulty hiring Turnover continues to be a problem Referrals continue at high rate Need to give it another 12 months
Problem: Post Care Coordination Growing number of post transplant patients (> 5K, 4K touched per year; 200-300 labs received per DAY) No additional reimbursement Care is task-oriented and reactive and not patient- centered Transplanting sicker patients Kidney outcomes flagged Readmission issues Nurse Engagement Scores (pulse) falling
Vision Four Foundational Characteristics and attributes of high-quality care coordination: Patient- and family-centered Proactive, planned, and comprehensive Promotes self-care skills and independence Emphasizes cross-organizational relationships Also consistent with Nursing Strategic Plan: Care Continuum: “ Practicing to the fullest extent of their expertise across the entire care continuum, acknowledged as a valued and respected professional” Outcomes: Meaningful and rewarding to the nurses Improves or sustains quality outcomes (clinical, functional, satisfaction and cost) (Antonelli,McAllister, and Popp,2009; McAllister, Presler, & Cooley, 2007;).
Proposed Solution Concentrate Expert Care Where it is Most Needed
Suggested Solutions Decrease patient load by more active referral back to community Automate lab checking Select low risk patients Replicate review Focus TNC efforts on complex patients with no more than 75 per nurse
Value- added TNC Activities Build caseload over three months Discharge patients from floor in collaboration with inpatient team Proactive calls to patient before first visit Baseline assessment with rest of care team including: Learning needs Presence of anxiety or depression – Stop D tool Falls risk and cognitive assessment (65 and older) TUG and MoCA With patient and family, develop care plan Follow up on missed care Facilitate referral to community physician at 3 months (parallel follow-up until first year visit) Follow patients for six months total and then rotate back to “pool” Proactive, coordinated care that is based on a caring relationship with the patient and family
Transplant Nurse Coordinator New Model 13 Two Nurses Closely Follow Patients for Three Months months123 case per dyadcase labs/day16.53345 per TNC81723 calls/actions1211 per TNC655 Clinic Visits * average all days not the same1213 per TNC677 number of patients2682138 per TNC134169 Note one week per month would be inpt - dyad mate would cover all pts
“ The Pool” Nurses follow patients 3 months to one year, high risk patients and all labs that hit “flags” Pool labs per day103109115111115119 FTE for labs (per day)222222 phone calls (all pts>3 months)83 Fte for phones2 other actions >3140 Fte111111 Total FTEs555555
Low risk labs of patients who have been referred to community Rotating Clinical Nurse from Clinic Briefly screen labs Facilitate prescription renewals Mark chart ready for letter Support staff will print letter and labs to patient and community physician low risk123129135141147153 rotating clinical nurse for low risk0.9 1.0 1.1
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