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Running head: EXECUTIVE SUMMARY CONSISTENT CARE

Executive Summary: Consistent Care

Amber Blankenship & Mary Ann Moultray
Western Washington University, BSN-RN Program
NURS 443: Interdisciplinary Care Coordination Practice Experience
Cathe Clapp
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EXECUTIVE SUMMARY CONSISTENT CARE
Executive Summary: Consistent Care
Purpose Statement
This care coordination project was conducted by a team of Western Washington University
(WWU) nursing students in conjunction with Karen Glover RN, CCM of Consistent Care in Snohomish
County. This agency is contracted with various local hospitals and works with them to identify frequent
users of the emergency department (ED). Once identified, Consistent Care case managers and client
advocates work together to develop a patient-centered care plan to both maximize quality of life and
prevent recurrent ED visits.
This documents serves to summarize the practice experience of the WWU nursing students, their
on-site participation, and deliverables provided at the end of the experience.
Problem Description
Consistent Care targets frequent users of emergency department (ED) services and as a result,
their primary demographic consists of those who experience homelessness, poverty, domestic violence,
substance abuse and/or chronic disease. Clients may experience any combination of these issues, making
for a very complicated patient load. This complexity is part of why case management is key to promoting
their success.
Process/Methods
The agency mentor, Karen Glover, assigned a new client to each of the WWU nursing students.
Care was given to select clients with complex social history. Each student was provided with: individual
patient ED chart notes, an emergency department information exchange (EDIE) report, narcotic
prescription report and outline of basic demographics. Pertinent information was collected from this chart
review and recorded on a patient information sheet. This was then used to begin conducting a needs
assessment based on what was known about the patients diagnosis, reason for ED visits, and document
social situation.
Students also attended a Consistent Care community health meeting where community
professionals discussed client cases and provided insight to further identify and meet patient needs. These
professionals included the president and founder of Consistent Care, Dr. Darin Neven, medical clinic case
managers, behavioral health social workers, county jail and police department social workers, emergency
medical services (EMS), and other community health professionals. The students participated by
presenting the new clients assigned by Karen Glover and giving a brief informational report regarding a
community resource centered around homelessness in each students respective community.
In addition, the WWU nursing students created motivational interviewing flowcharts for specific
diagnoses to aid client advocates in the interviewing process. This project was done after Karen identified
a need for client advocates, who are typically not a licensed medical professional, to have a basic guide on
the interview process.
Key Findings & Results
Through observation, practical experience and discussions with Karen Glover, the students were
able to witness the orchestration of the Consistent Care program. Students both observed and participated
in the process of identifying the clients individualized needs and motivational factors leading them
frequent the ED. Factors varied from simple causes such as not having established care with a primary
care provider (PCP) to more complex causes related to social insufficiencies such as a lack of housing
and/or transportation or unmet behavioral and mental health needs or chemical dependency.
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EXECUTIVE SUMMARY CONSISTENT CARE
Snohomish county has many resources available for this population. This includes housing,
financial, social support, behavioral health and substance abuse treatment resources. In addition to this,
Consistent Care has pulled together a group of individuals representing these various resources. This
group meets monthly to collaborate on the complex nature of these caseloads and identify how to best
connect clients to these resources.
The community health meeting held by Consistent Care proved to be a very informative meeting
in which the many facets of community resources were able to creatively think and problem solve
together. This manner of collaboration was striking and serves as an inspiration for care coordination in
other healthcare settings.
Deliverables
As part of the consistent care team, client advocates are often performing face-to-face meetings
and work with the client to address their needs. Because these advocates have minimal medical training,
the students created motivational interview flowsheets based on common medical diagnoses to assist the
advocate in the interviewing process. Questions centered around chronic disease management and a brief
assessment of their access to resources such as food, shelter, transportation, etc.
Recommendations
The WWU nursing students felt that Consistent Care provides a well-rounded service. Their
commitment to patient-centered care and collaboration of the healthcare community is impressive. As a
result of this practice experience, the WWU nursing students recommend the following:
Expand the Consistent Care program to Whatcom County
Consider having future cohorts create additional motivational interviewing flowcharts for other
diagnoses such as, diabetes, smoking cessation, substance abuse, etc
Conclusion
The Consistent Care team demonstrated strong care coordination skills. They understand that for
frequent users of ED services, the heart of the issue is rarely medical. Instead, these clients are often
grappling with numerous social barriers. By acknowledging them, the team can better prioritize the care
and set the client up for success by providing the tools and resources necessary.
It would be wise to explore an approach similar to Consistent Care, focused on hospital
readmission rates. Reportedly, one in six [Medicare] patients returned to the hospital within a month of
leaving the hospital after receiving medical care (Goodman, Fisher, & Chang, 2013). Consistent Care
has been very successful and has seen a reduction in use of ED services by 34% (Murphy & Neven,
2014). But, their methods may also prevent hospital readmissions. This is because unlike hospital case
managers, the Consistent Care team is able to follow these clients out in the community and continue the
support after discharge. And, a reduction in hospital readmissions has implications which are beneficial
for both hospitals and their patients.
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EXECUTIVE SUMMARY CONSISTENT CARE
References
Goodman, D. C., Fisher, E. S., & Chang, C. (2013). After hospitalization: A dartmouth atlas report on
readmissions among medicare beneficiaries. The Dartmouth Institute for Health Policy and
Clinical Practice. Retrieved from
http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf404178
Murphy, S. M. & Neven, D. (2014). Cost-effective: Emergency department care coordination with a
regional hospital information system. The Journal of Emergency Medicine, 47(2), 223-231.