Case Study: Preventing Unnecessary Hospitalizations

An HFMA Healthcare Financial Pulse Resource

The St. Vincent’s Nurse-Managed Health Clinic, which opened last fall in Galveston, Texas, has a first-year expense budget of a mere $225,000. But that is not the figure clinic director Kathryn Fiandt, DNS, FAANP, focuses on. Her sight is set on the number 20—as in preventing 20 unnecessary hospitalizations.  

“If we avoid 20 hospitalizations in the course of a calendar year, we will break even,” says Fiandt, who is also the associate dean for graduate programs and clinical affairs at the University of Texas Medical Branch’s (UTMB’s) School of Nursing.

Fiandt was recruited to UTMB specifically to establish business-smart nursing practices. Her first project was to establish a partnership with St. Vincent’s House, a social service agency, to offer a free health clinic for uninsured patients. Although the clinic, located at St. Vincent’s, serves all uninsured adults who show up, its focus is to provide what Fiandt calls “intensive primary care” to a roster of more than 200 patients who are frequently hospitalized at UTMB because of chronic illness, including hypertension, diabetes, and mental health problems.

Before Fiandt arrived, these patients had been assigned case managers through UTMB. But the healthcare system is not set up to meet the many needs these patients have. As a result, these patients are often admitted to the hospital because their conditions get out of control--averaging 1.75 hospitalizations per patient a year. Each inpatient stay costs the hospital an average of $13,000, so preventing 20 hospital visits by uninsured patients will save the hospital $260,000.

Giving Comprehensive Care

The clinic has had nearly 700 patient encounters since it opened in September. And she’s optimistic the clinic will meet its goal of preventing 20 hospitalizations by the end of August. The clinic maintains narrative logs for its patients, and Fiandt believes that at least 10 patients would have been hospitalized to date if not for interventions they received through the clinic. (However, Hurricane Ike has complicated Fiandt’s data collection. Because UTMB was closed in the wake of Hurricane Ike, the clinic served many patients that would ordinarily have been served at the medical center, which has complicated tracking patient outcomes.)

Fiandt, who specializes in family medicine, works with one full-time nurse practitioner, a medical assistant, and two School of Nursing faculty members who each work one half-day per week. The advanced practice nurses represent four specialties: family medicine, adult medicine, psychiatry, and women’s health.

Frequent and comprehensive contact with these patients is key, Fiandt says. “These are not 15-minute visits,” she says. “These are not people that you can say, ‘OK, your diabetes is out of control; here’s a prescription, take this and see me in three months.’”

In fact, a typical appointment may last up to an hour at the beginning. The patient’s case manager also participates in these appointments. “We get a comprehensive picture of what the needs are in partnership with the patient and the nurse case manager,” says Fiandt. “This way I know that when I say, ‘I’m going to change the way you do this’ or ‘I want you to do this,’ I’ve got the case manager who’s going to be working with this patient to make sure it happens.”

Coordination and follow up are a big part of meeting the complex needs of clinic patients. “The problem isn’t following the national guidelines in terms of what meds or tests are needed,” says Fiandt. “The problem is mobilizing the resources to make that happen, working through the system, ordering their meds on pharmacy assistance, doing home visits to help them understand what to do, etc.”

How to Get Started

Fiandt, who joined the UTMB nursing faculty in 2007, worked with UTMB’s vice president of community outreach and the dean of the nursing school to develop the St. Vincent’s program.

The clinic opened about a year after she arrived and is modeled after a similar operation she started at the University of Nebraska Medical Center. Fiandt suggests that other healthcare providers who wish to adopt this model should consider locating the clinic outside the hospital system. In her case, the clinic is owned by St. Vincent’s House, which contracts with UTMB School of Nursing to operate and staff the clinic.

This allowed the clinic to start without some time-consuming and expensive requirements that automatically come with hospital affiliation. For example, if the clinic were part of the UTMB system, the clinic would be required to use UTMB’s electronic medical record (EMR). But the IT and financial support needed to make the EMR work for the small, off-site clinic would have been hard to come by. In addition, because the clinic is outside the UTMB system, Fiandt can work on her protocols and procedures rather than adopting those already in place for a 500-bed hospital affiliated with a medical school and a nursing school.

“My goal will eventually be to become part of the health system when we’re ready,” she says. “But, for right now, we did not need the constraints that come with being part of a big system.”

The St. Vincent’s House location provides two big advantages. For one, the agency had space that had previously been used as a medical clinic, so Fiandt’s clinic did not have to build out the space. For another, St. Vincent’s House provides the space at no cost. To get the clinic started, UTMB’s hospital clinic donated some equipment and supplies while community organizations, such as a diabetes center, contributed other equipment.

The $225,000 first-year budget also provided funds for some equipment, although it primarily covers personnel costs, including one full-time nurse practitioner, one full-time medical assistant and part of Fiandt’s time and her assistant’s time. Fiandt’s assistant provides bookkeeping, orders supplies, and provides other clerical support for the clinic.

The clinic can comfortably handle about 10 appointments a day, although it is currently seeing up to 18 patients a day. Case managers work directly with the nurse practitioners to make appointments for their clients.

Other Tips

State law required the clinic to have a medical director, which must be chosen carefully. “That took several months because I needed to find a person who understood what we were doing and what our needs were and who was willing to trust our competencies,”says Fiandt.

If many of your patients do not speak English, hire bilingual staff members. At St. Vincent’s, about one-third of the targeted patients are Hispanic so having a nurse practitioner and medical assistant who speak Spanish increases the likelihood that those patients will use the clinic’s services.

Develop a referral network for services that the clinic does not provide. For example, while St. Vincent’s is organized to serve as a patient’s healthcare home, Fiandt’s staff is not equipped to provide chronic pain management for patients with substance abuse problems. So those patients are referred to a community health center.


Interviewed for this article: Kathryn Fiandt, DNS, FAANP, is associate dean for graduate programs and clinical affairs at the UTMB School of Nursing’s Center for Nursing Practice Development in Galveston, Texas. (klfiandt@utmb.edu)

Publication Date: Friday, May 01, 2009

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