Presented to: Insert relevant presenter information Calibri 16pt Presented on: Month day, Year Presented by: Insert relevant presenter information here Presented to: Region 7 Collaborative Educational Forum Presented on: February 13, 2015 Presented by: Gwen McNatt, Director Staffing Models in Transplantation

Problem: Pre kidney Growing number of referrals No additional transplants Nurse Engagement Scores falling Nurses burning out, high turnover

Background FTEs (actual) FTEs (budget) TNC (RN/ PA) RN/PA Turnover new pts intervalHQslistedwaitlistDDLDKP/Pcomments visit per FTE transplant per FTE total pts per TNC (lds,new interval, waitlist) Tx per TNC Year % % added RN at mid year % % % % RIF, leadership change X % volumes projected; leadership change x

Comparison Centers Center referrals per year list size DD tx LD txTotal SPK/Pa nc #RNs#Support on call CommentsOther JHopkins / have regular and incompatible teams - 3 person on call/waitlist team plus manager St Barnabas yes also manager/APN who coordinates all KPDs UCLA of support team LPNs; 5 person call team Calculate minutes per visit + case followup x # of patients seen x 80% staff productivity in minutes per day determines # FTEs UC Davis yes post nurse share in call - so 10 total

Proposal PatientsStats/VisitsBenchmarkratio per TNCprojectedneed Staffing Cost (Salary & Benefits) New- LD Recipientsnew visits ,366 New-DD Recipientsnew visits ,347 Waitlist management/interval visits/kp patients interval visits + KP new and intervals 160 (No Pancreas) ,847 Living donorsPhase 3 visits NA ,712 NA 91,123,272 Organ Offers (procurement tech) NA 1111,890 Current TNC Staffing 6 Proposed TNC Staffing 9 Variance (3) Procurement Tech for Kidney (1) Total Variance to Current Staffing 4

Results? Difficulty hiring Turnover continues to be a problem Referrals continue at high rate Need to give it another 12 months

Problem: Post Care Coordination Growing number of post transplant patients (> 5K, 4K touched per year; labs received per DAY) No additional reimbursement Care is task-oriented and reactive and not patient- centered Transplanting sicker patients Kidney outcomes flagged Readmission issues Nurse Engagement Scores (pulse) falling

Vision Four Foundational Characteristics and attributes of high-quality care coordination: Patient- and family-centered Proactive, planned, and comprehensive Promotes self-care skills and independence Emphasizes cross-organizational relationships Also consistent with Nursing Strategic Plan: Care Continuum: “ Practicing to the fullest extent of their expertise across the entire care continuum, acknowledged as a valued and respected professional” Outcomes: Meaningful and rewarding to the nurses Improves or sustains quality outcomes (clinical, functional, satisfaction and cost) (Antonelli,McAllister, and Popp,2009; McAllister, Presler, & Cooley, 2007;).

Expert nurse care coordinator

Proposed Solution Concentrate Expert Care Where it is Most Needed

Suggested Solutions Decrease patient load by more active referral back to community Automate lab checking  Select low risk patients  Replicate review Focus TNC efforts on complex patients with no more than 75 per nurse

Value- added TNC Activities Build caseload over three months Discharge patients from floor in collaboration with inpatient team Proactive calls to patient before first visit Baseline assessment with rest of care team including:  Learning needs  Presence of anxiety or depression – Stop D tool  Falls risk and cognitive assessment (65 and older) TUG and MoCA With patient and family, develop care plan Follow up on missed care Facilitate referral to community physician at 3 months (parallel follow-up until first year visit) Follow patients for six months total and then rotate back to “pool”  Proactive, coordinated care that is based on a caring relationship with the patient and family

Transplant Nurse Coordinator New Model 13 Two Nurses Closely Follow Patients for Three Months months123 case per dyadcase labs/day per TNC81723 calls/actions1211 per TNC655 Clinic Visits * average all days not the same1213 per TNC677 number of patients per TNC Note one week per month would be inpt - dyad mate would cover all pts

“ The Pool” Nurses follow patients 3 months to one year, high risk patients and all labs that hit “flags” Pool labs per day FTE for labs (per day) phone calls (all pts>3 months)83 Fte for phones2 other actions >3140 Fte Total FTEs555555

Low risk labs of patients who have been referred to community Rotating Clinical Nurse from Clinic Briefly screen labs Facilitate prescription renewals Mark chart ready for letter Support staff will print letter and labs to patient and community physician low risk rotating clinical nurse for low risk

Outcome Metrics Patient Survival - IMPROVED Graft Survival- IMPROVED Readmission Rate – Markedly improved Patient Satisfaction – over goal Employee Engagement – We’ll see???

Questions?