Risk Stratification Necessitates Nursing Coordination

By Gina Tabone

The Dictionary of Modern Medicine defines risk stratification as “the constellation of activities, i.e. lab and clinical testing used to determine a person’s risk for suffering a particular condition and need – or lack thereof – for preventive intervention.” Any discussions concerning risk stratification must then, include how identified patient needs will be managed and coordinated. Categorizing those most at risk is useless if there is not an actionable plan in place to provide 24/7 treatment.

In order to accomplish this, several items need to be addressed. These include:

  • Coordination of care
  • Active communication
  • Continuous access to care
  • An understanding that now may be the time to consider partnering with an external team of caregivers to provide care for all patients regardless of their determined risk level

In today’s healthcare world, the familiar saying, “the right hand doesn’t know what the left hand is doing” is often true. Health systems are complex, multi-specialty organizations that can offer patients multiple services and interventions on any given day. The following scenario helps illustrate this:

Recently, a COPD (chronic obstructive pulmonary disease) patient was being discharged from an inpatient setting after being treated for an acute respiratory infection. On day two of her seven-day admission, a Foley catheter was inserted due to a sudden onset of urinary retention. Urology has not been able to identify the cause of the retention; as a result, the catheter will remain in place when the patient is discharged.

Nowhere in the discharge instructions was there any mention of the catheter or how to care for it. When the patient’s daughter asked the discharging provider what she needed to do with the catheter once they left the hospital, she was shocked by the response: “What catheter?” That was not what she expected to hear, nor did it make her feel confident about taking her mother home.

This patient was identified in her electronic medical record (EMR) as a high-risk patient and has three comorbidities. She recently suffered a stroke that compromised her entire left side and had been hospitalized twice within the past twenty-five days. There was no indication that a designated care coordinator was involved in the patient’s plan of care.

Not only would the patient’s overall health status have benefited from dedicated coordination efforts but so would the ability to contain the costs of her ongoing care and reduce preventable readmissions. When questioned about care coordination oversight of patients, the assigned RN was not aware of any such role at this facility. That explains a lot.

The importance of the EMR has been proven and is universally recognized. In this case, every provider involved in the provision of care documented each encounter in the patient’s EMR. The problem occurred when some of the caregivers failed to read crucial details in the record. While clinicians are busier than ever and often limited with their time, it is vital that they dedicate the time needed to gain a comprehensive view of the patient’s health status. If this does not happen, care simply cannot be effectively coordinated. Taking the time to read all of the information included in an EMR will not always be a reasonable expectation, but there is a solution.

Care coordinators need to be assigned to navigate care, communicate prioritized information, and advocate for patients when necessary. The patient mentioned above is an example of a high-risk patient. The level of acuity in this scenario represents the level of acuity found in 15 percent of the population. The alarming fact is that while only 15 percent of patients are stratified as high-risk, their care consumes more than 80 percent of overall healthcare spending. Delegating registered nurses as care coordinators to offer constant access to the supervision of chronic and acute health needs is the essence of optimal patient outcomes. The tool that makes this possible is the EMR.

Patients at high risk need ongoing care coordination that is consistent and predictable. The fact that most of the population is not high-risk does not necessarily imply there is no need for harmonious care. Mid-risk and low-risk patients also are best served by a coordination of care that focuses on either maintaining or improving current health status.

However, designating a workforce of RNs to be accessible 24/7 is not always feasible. Many organizations are challenged with having enough bedside nurses available for basic 24/7 staffing requirements. These nurses often cannot be spared to care for patients calling in from a remote location. Secondly, having RNs available if patients call may not be economically feasible for cost-conscious organizations. Granted, this does not apply to the higher-risk patients but rather to those who would benefit from speaking to a clinician as needed.

Patients often do not know what they should do when they are ill or require medical care, especially when their provider’s office is closed. While it is common for patients to seek immediate treatment, it is not always necessary to receive care at an emergency department (ED) or urgent care. Directing patients to the most appropriate level of care fosters optimal utilization of clinical resources.

Often, a trained triage nurse can offer symptom-specific interim care and guide patients to an appointment with their provider the following day as a safe option. No one wants to go to the ED if it is not necessary and end up having to incur expensive co-pay costs. Healthcare organizations need to include remote medical care for all risk levels when developing a strategy to provide access to care. Maintaining and improving the health of low-risk patients has the potential to generate revenue that can support and sustain other necessary care coordination expenses. With this it is easy to see that care coordination is the best option for both the patient and the organization.

We did not arrive at the current state of healthcare overnight. It has been a gradual evolution. As such, the necessary changes will not happen overnight, either. A reform effort such as risk stratification is a great example of an initiative designed to improve patient outcomes without compromising the practices that positively affect patient and population health.

Today’s healthcare consumers are treated by a variety of providers, often at different locations, and sometimes in different networks. The role of an RN care coordinator is critical to managing the entire continuum of care for patients. The EMR allows the RN to know what is occurring in real time and to make sure that treatment plans are being implemented as intended. They also are able to identify gaps in care and hold all members of the interdisciplinary team accountable.

Many organizations are in the process of designing care coordination departments, but as with the development of any new program, there are challenges that may prove detrimental to patient care. Now is the time to consider working with a medical call center so that the transition is smooth, with minimal risk to patients. Triage nurses are available 24/7 to care for high-, mid- and low-risk patients on demand. Technological capabilities also enable the transmission of information directly to the individual’s EMR.

Risk stratification is long overdue, and it is here to stay. To achieve the desired outcomes, be sure that qualified telephone triage nurses are involved.

Gina Tabone, MSN, RN-C, is the vice president, strategic clinical solutions at TeamHealth Medical Call Center.