UW Medicine – Complex Care

UW Medicine is one of the top-rated academic medical systems in the world. With a mission to improve the health of the public, UW Medicine educates the next generation of physicians and scientists, leads one of the world’s largest and most comprehensive biomedical research programs, and provides outstanding care to patients from across the globe.

Cardiology Clinic

Nurses in the Cardiology Clinic provide personalized supplemental services and support to high-risk cardiac patients to build trust and address social barriers to health. Tools include home visits, additional inpatient bedside visits, providing snacks and scales during visits, allowing walk-in and longer outpatient appointments, and medication management. Home visits include dropping off medications, assistance with grocery shopping to teach about nutrition and salt intake, and relationship-building visits. How does this build trustworthiness? This personalized care demonstrates caring and provides equity and fairness to patients from historically marginalized populations.

How It Works

Our Cardiology Clinic nurse maintains a spreadsheet of high-risk heart failure patients whose chronic illness is managed by our providers. We use this list to monitor who has had frequent hospital admissions or ER visits, lost to follow-up, transitioned from homelessness, or any other life transitions that may require increased care coordination to maintain health. Our nurses engage with the patient by having frequent nurse visits which include clinical assessment, education, and provider-directed interventions. They also provide telephone follow-up and assessment phone calls, sometimes as frequently as daily, when a patient is in transition. The nurses prioritize bedside visits during an inpatient admission. Nurses engage the patient through timely (< 1 week) post-discharge follow-up and other varying and frequent modes of check-ins. Close collaboration between the nurses, providers, and multi-disciplinary teams to create patient-specific care is crucial when developing trust with our patients because they know that our team works closely together to meet their needs. Our nurses also collaborate with allied providers such as social work or pharmacy thus provide multiple opportunities for support and intervention. Weekly multidisciplinary meetings include discussions led by nurses regarding these patients and their specific clinical, educational, and communication needs. To further facilitate close management of our patients, our clinic has established lines of communication with community partners, such as case managers. Our nurses also provide occasional home visits, which galvanize trusting relationships when the patients see we are willing to go out of our way to help them.

Skills and Competencies

Our nurses are credentialed in heart failure management allowing for excellent medical care and a strong grasp of the condition. They also provide critical social and emotional support for patients living in supported housing and low-income areas. Our staff is particularly skilled in active listening and non-judgmental conversations, allowing the patient to convey their struggles to properly manage their chronic illness. Staff also require patience, persistence, and consistency to build and maintain a trusting relationship. The ability to follow-through on a plan, and not over-promise, is also essential to build and maintain trust.

Origins

The population we serve at the county hospital, in a growing metropolitan city, is very marginalized and poor, with generations worth of mistrust in the medical system. Our problem was that a diagnosis of heart failure requires tight management for optimum care to prevent costly hospital stays and premature death. We saw increased readmission rates and ED visits with our heart failure patients in particular. The nurses in this clinic found the more trust they built with their patients the better the outcomes of their chronic disease.

Effectiveness

Our primary indicators of effectiveness are patients’ statements of trust and active engagement with staff during visits. Some patients progress from declining to come to the hospital to active engagement beyond the clinic to include the wider healthcare system. The practice has resulted in reduced 7 day and 30-day readmission rates among recipients Many patients who previously had frequent ER and hospital admissions due to medical non-compliance reduced their admission rate to zero or infrequent after engaging with our clinic and demonstrably improved their medical compliance. We have also helped homeless patients obtain housing by providing consistent access and communication that allowed the patient to work with social workers, community partners, and government agencies to meet bureaucratic requirements to get housing and other social services.

Scalability

Currently, this practice is only in one location to serve the needs of a particular chronic illness group. A similar practice occurs in our HIV clinic but relies on social workers instead of nurses. This practice can be scalable if financial resources are improved through adjustment of definitions of billable services and improvements in insurance reimbursement for these types of outpatient services. Scale can also be increased if patient loads for nurses (and social workers) are maintained at a more manageable level.