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Nurses Team Up to Help Patients Stay Well

The last thing any person wants after returning home from the hospital is to be readmitted. Saint Francis is beginning a new nursing model that aims to provide more targeted care to reduce the number of readmissions.

Under this model, called Practice Partners, registered nurses (RNs) and licensed practical nurses (LPNs) work in teams to provide a higher level of care for patients. The RN assesses the patient and creates a plan of care for the patient that focuses on reducing complications, improving outcomes and patient satisfaction. The LPN works closely with the RN to perform the appropriate patient interventions.

In this new program, LPNs will be caring for patients’ basic needs such as mobility, skin care and medications. Patients will benefit because the LPNs have a high level of training and education and can continually observe the patient’s physical and mental state along with the patient’s response to care.

Practice Partners also requires that nurses complete a “frailty assessment” for all patients 65 and older to identify whether they are at risk for readmission and to identify any special needs. A Medical Center pharmacist will evaluate the patient’s medications to determine the effectiveness of the medication regimen and to evaluate for any adverse reactions.

An Advanced Practice Nurse (APRN) who assists in the care is a part of the multidisciplinary team.  This APRN focuses on the care being given to each patient giving input to the Practice Partners for the plan of care, evaluates with the care team the goals to be accomplished within the established discharge date and  identifies possible  reasons  for  readmission to the hospital.

We are constantly evaluating our care processes and delivery system to find ways to improve patient outcomes and one of these is to provide an improved quality of life for the patient by avoiding a readmission to the hospital.

For more information, call 573-331-3000.

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