Jenny Moyer remembers well the elderly gentleman’s dedication to his critically ill wife. Every day for two months, he came to his wife’s room on the cardiac surgery intensive care unit to sit by her side. Gradually, Moyer and other caregivers noticed that he was wearing the same clothes every day and that he never ate. Slowly, his vigilance turned to weariness.

Then the care team learned that he was uncomfortable eating a meal in the room while his wife was being feed through a tube. “So we ordered an extra meal and the nurses took turns eating with him,” recalls Moyer, a nurse clinician III on the CSICU.

This small, poignant interaction illustrates the “total care management” model that Hopkins Hospital has employed for nearly eight years. Its premise is to make everyone who touches patients and their families a vital link in delivering efficient medical treatment, relying on nurses to provide the care coordination.

That multidisciplinary approach to patients has lowered such hospital indicators as length of stay and cost per case. As a result, the University HealthSystem Consortium recently recognized the Hopkins model as one of the top three in the country.

The Hospital consistently exceeded national standards, according to the UHC’s care coordination benchmarking project. For example, Hopkins (and the other top performers, Harvard’s Brigham and Women’s Hospital and Toledo’s Medical University of Ohio) exceeded length of stay expectations (0.97 compared to the target of 1.0 and the national average, 1.03), meetings with spouse, family or significant other within seven days of admission (93.4 percent compared to target of 94 percent and national average of 53.2 percent), and detailed discharge instructions (97.4 percent compared to target of 100 percent and national average of 61.6 percent).

The Hopkins model came out of a need to improve the quality and cost efficiency of caring for patients, from admission to discharge. The prevailing opinion was that everyone, from attending physicians to residents and from respiratory therapists to social workers, had to work as a team in treating patients.

But these caregivers rotate in and out during a patient’s hospital stay, so the responsibility of coordinating care and constantly screening for changing patient needs rests with the bedside nurse. On some units, this pivotal role falls to the nurse clinician III; on others it might be the nurse practitioner. But whatever the title, as Assistant Nursing Director Terry Nelson puts it, “the nurse is the one constant presence.”

-From Hopkins Nurse, Fall 2006

PHOTO:  Multidisciplinary care coordination here has been cited as a national model thanks to the work of nurses throughout the Hospital, including, from left, the CSICU's Shanta Robinson, Jenny Moyer and Christina Savage.