Before the New Year, we need to step back and figure out how to add value to our patient care starting at the level of the visit. This is the only way that we are going to improve outcomes and reduce costs simultaneously. Both cost reduction and outcomes improvement are imperative for survival in 2012.
One way we can do this is to turn our attention away from patient education. It does not work. Every day I read something like, ‘taught to eat low sodium diet. Pt. Verbalized Understanding.’ I can easily see how such highly skilled care would keep a patient out of the hospital especially when his hypertension has exacerbated three times over two episodes.
In order for our patents to get better, they must change their behavior. They must develop skills that they didn’t have before.
I love sports. Once I suffered through an incredibly boring conversation with my Dad (an engineer) about the physics involved in hitting a home run so I know a lot about hitting homers and my Dad knows even more. Neither of us has ever hit one, though. My son, on the other hand, regularly hit the ball out of the field (and onto cars passing by but that’s another whole blog about auto safety near ballparks).
Sadly, my son really doesn’t know a lot about physics; nor does he care. In fact, nobody ever really ‘taught’ my son to play ball. A couple of men over the years coached my son and countless other boys and young men into becoming competent players.
The first thing that a coach assesses is who really wants to play ball. Until college, all that’s required to play is willingness. There are good players and bad players but everyone gets a little better as the season goes on because they like playing ball.
Coaches always build on the basics. They start off with fundamentals before they move onto more complicated plays.
Coaches set goals. They obviously like to win but long before the season even starts, they are coaching players to improve their stats a little at a time.
Coaches ‘motivate’ players. Some of us are a bit put off when coaches call players ‘sissies’ and use language no child under 35 should ever hear but I must admit it is effective.
Finally, there isn’t a coach worth their whistle that doesn’t keep up with the numbers. Baseball is all about statistics. Football – not so much – but I guarantee you that every coach knows the number of yards, field goals, etc. that their team accomplished during last week’s game.
How do we apply that to patient care? Starting at the beginning we have to get our patients to ‘want to be on the field’. But we also know that less than one percent of people who play sports growing up become a professional athlete. (We also know that some people willingly play football for Alabama and I can only guess it is because they are desperate for an education or just love football and this blog could not begin to cover that psychopathology). In other words, for most athletes, the reason why they play is because it adds quality to their life. So start by finding out what your patient considers important to his or her quality of life. Here are a few suggestions I wrote a few weeks ago.
Build on the basics. If you are admitting a patient newly diagnosed with hypertension, what is the first thing that he should know? For most people it would be how to take medications safely but not always. Your patient may be obsessive about medications but feels that with all the pills he or she is taking they can eat anything they want. That would be the first basic need for that patient – adhering to a low sodium diet.
We are very much aware of our nursing goals on the care plan but what about the patient’s goals? How does he or she know how well they are doing? Feedback is critical when changing a behavior. Setting small goals is important so that our patients can enjoy some success on their way to the big leagues and we can intervene when the numbers move too much in the wrong direction.
Obviously, no matter what kind of day we are having, we are not allowed to yell at patients or to call them sissies. We are not allowed to threaten them, bribe them with money or chocolate (esp if diabetic) or otherwise coerce or harass them into doing what we want them to do. Isn’t that just like Medicare? They task us with making homebound patients well and then they tie our hands with all these stupid rights and responsibilities.
So, that leaves us with motivating a patient by turning their goals to our goals. The patient’s goal may be to get clearance from his MD to drive a car again. Your nursing goal may be to get the patient to comply with a reduced sodium diet and lose weight. Work it, baby! Coach the patient on keeping a food diary and daily weights. Give the patient tools to monitor his numbers. Get the patient to practice! Involve the patient as much as possible.
How many times do you get the feeling that a patient has just given up? They have tried for years to cope with their hypertension and blood sugars, etc. and quit caring a long time ago. Let them see some success. Regularly. Remember, they may have tried before but this time they have you as a nurse and let that be the difference between past failures and future success.
Finally, keep up with the numbers. Don’t set a system in place for a patient and never follow-up. It is a very powerful tool to hold someone accountable for their behavior. Often, just knowing that the nurse is going to weigh them and look at their food diary and daily weights is enough to get them through a rough spot. Call them once or twice a week if they have forgotten to weigh themselves in the past week. Use a free internet text messaging system to text them in the mornings. Be creative.
As the patient begins to experience success they will undoubtedly enjoy feeling better, too. Each week, keep adding to their playbook. Replace one or two visits with a phone call if the patient is doing very well. This will give you the resources to take care of the patient in the unlikely event of another exacerbation.
When the patient has enjoyed a stable blood pressure for a few weeks and has lost weight and is eating well on a low sodium diet, do not discharge the patient. Graduate them! Give them a certificate of recognition for taking back control over the disease process that was controlling them. They deserve it. After all, if you did your job right, most of the real work was done by the patient. You were just the coach.
That kind of care and follow up is something I would pay 120.00 for if my mom or dad needed it. I would pay a bonus if you were subjected to a spontaneous informercial on the physics of home runs and why an ultra-light baseball bat is important to the process. I would understand, however, if you quit when he decided it was time that you learned how to use a slide rule. No one gets paid that much.