First FNP in New Mexico to start Project Re-Engineering Discharge (RED) for Congestive Heart Failure (CHF) Patients
Pros: variety of patients
Cons: never enought time in the day to fully complete each patient encounter.
(Typical hours were 8:00 AM to 5:00 PM Monday through Thursday at hospital, and 9:00 AM to 3:00 PM on Fridays for clinic appointments) Objective was to decrease 1 month readmission rate of CHF patients for Christus St. Vincent Medical Center and provide close follow-up for same patients at the New Mexico Heart Institute (NMHI) in Santa Fe, NM. I would select appropriate patients after review of hospitalist notes in morning. Depending on severity of symptoms and date for discharge, I triaged in-hospital patient visits for that day.
Collaborated with Pharm. Drs. to establish complete list of discharge medications and appropriate doses for each patient. In afternoon, I would visit selected patients, present personalized folder for at home care and discuss each item. At time of patient discharge, I would collaborate and schedule 1 week follow-up appointment with me at NMHI. The hospital and NMHI were in the process of collaboration of services at the time of my employment, and decided to terminate the position after only 5 months of existence. Unfortunately my immediate manager was unable to exercise any control over the situation. I gained a tremendous amount of knowledge regarding the identification and treatment of multiple types of CHF, teaching tools, & utilization of EHRs at the hospital and clinic. I was fortunate to work with great cardiologists, nephrologists, RNs, hospitalist physicians, and case managers. I thoroughly enjoyed interacting and teaching the patients and their families about the CHF disease process and their role in managing the disease process. The hardest part of the job was patient identification. There was no IT program or IS person in place to assist with identification of patients by DRG codes, symptomology, or other markers of CHF. The second most difficult part of the job was not being able to finish what I had started,