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)