Working the System

A gentleman on my case-load with relapsing and invasive cancer was transferred from the hospital where I have rounding priviledges to an acute care facility where I do not. While he was inpatient, I was able to have direct contact with the social worker, floor nurses, oncologists, and dietician, my input readily received and documented in the chart each time I visited.

When one of my patients leaves our hospital system and is sent outside the network, my ability to advocate and act on their behalf is made astronomically more challenging. Based upon the receptivity of the facility, my job as liaison and advocate can take on a very different tenor. That said, even in the hospital where I have priviledges and can write in the chart and be part of the decision-making process, there are still providers who question my role, having never heard of a "nurse care manager" and wondering what business it is of mine--lowly nurse that I am---sticking my clinical nose in their care. Overall, though, any help from the outside is generally welcome, and I serve as a critical link to family, the primary provider, the visiting nurses, the other specialists involved in the patient's outpatient care, and I hold crucial information that may otherwise fall through the cracks. Not many people---especially not those on Medicaid---have a dedicated nurse who will follow them through every admission and discharge, running interference and clearing the way for quality care (as well as visiting them at home and occasionally accompanying them to specialist visits). The fact is, I don't even think people on premium plans have such a service. It is so far outside the norm that many people just don't think it's possible. But here I am.

Arriving at the new facility where my patient had been ensconced less than an hour, I realized that I had arrived at the 3pm change of shift, a mixed blessing. While everyone was around at this time, it is also a point in the day when the "hand-off" occurs, and the team who has the patients for the next eight hours wants a full and comprehensive report. An unannounced guest from an outside agency demanding time that no one has is not always welcome. But this was my lucky day.

The floor nurse for the shift was not hard to find, and we quickly realized that she had graduated from the same LPN program that I now teach for, but prior to my short teaching career. Within a few minutes of my talking about the patient, she realized that I was a gold mine of detailed information, not only about the recent hospitalization, but about the entire course of my patient's disease as well as his social history. She acknowledged how a new patient arriving with a stack of papers from another facility and very complicated needs often poses a challenge for the receiving facility. Was anything missed? Is this med list complete? Are their special needs not mentioned? I can't even count how many times hospital discharge orders are inaccurate or incomplete. It's basically my job to pick up the pieces.

After meeting with the ever-so-receptive nurse, the next stop was the Nurse Practitioner who works the floor. She was much less amenable to a conversation but I scribbled her name in my book and gave her my card, being sure to make eye contact and shake her hand.

Entering the patient's room, luck would have it that the rounding doctor had just drawn the curtain to begin his examination of the patient whose tracheostomy currently precludes his ability to speak. My intervention at this point provided some crucial information regarding my patient's desires in terms of advance directives, need for frequent suctioning, an ulcer on his sacrum, recent problems with his g-tube, his home situation. The doctor was exceedingly receptive and we agreed to be in touch weekly.

Feeling like I had already hit the clinical jackpot, in walked the physical therapist, a woman whom I had actually ridden up on the elevator with when I first arrived---we had exchanged friendly smiles during that brief ascension from the first floor to the third. She was also very receptive to my input and agreed to stay in contact.

My patient grinned at me from ear to ear, mouthing the words "thank you". He knows my lip-reading skills are awful, but "thank you" is pretty easy to decipher. He hates to have to use pen and paper but also knows that I'm useless to him otherwise when it comes to getting his point across. My lip-reading neurons must have been destroyed by adolescent marijuana use.

The next day, I returned and my good luck continued, the very friendly and responsive respiratory therapist in the room when I arrived. We had a long chat about our mutual patient until the very same physical therapist arrived, and I left my patient in her capable hands.

Yes, I will concur that the healthcare system in this country is generally broken, or at least crippled. Quality and continuity of care is often lost in the fiscal shuffle and the protection of the bottom line, as well as due to the ever increasing rates of malpractice insurance driven higher by our litigious society. I also concur that even my work is hindered by constraints and roadblocks that cause no end of consternation and cursing. However, when I can use my skills and professional collateral to finesse an improved outcome---whether momentary or long term---this is a coup, a small victory, and a moment for satisfied reflection.