Improving Outcomes, Discharge Planning for Complex Urologic Surgery

Transcription:

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And in this panel today to discuss improving outcomes and discharge planning for complex urologic surgery is Dr. Stephanie Kielb. She's the Chief of Reconstruction and Neuro-urology, a Professor of Urology, Medical Education and Urogynecology. And she's the Director of the Transitional Adult Congenital Genitourinary Clinic at Northwestern Medicine and Mara Markzon. She's a Clinical Social Worker in the Department of Urology at Northwestern Medicine. I'm so happy to have you both with us today.

And Dr. Kielb, I'd like to start with you as we're getting into this topic and discharge planning and better outcomes. I'd like you to first tell us what constitutes complex urologic procedures for other providers. Tell them what we're discussing today.

Stephanie Kielb, MD (Guest): So, complex urologic procedures, really, in my mind, I think of it as patients that require some genitourinary reconstruction, reconstruction of their urinary tract utilizing pretty advanced techniques but mainly involving utilizing pieces of the intestine, whether it's the small bowel, the colon, the appendix to improve their sort of urinary management.

And these are complex surgeries which are done mainly in tertiary care centers, which involves a significant amount of skill, but also requires some recovery from the patients. We're not talking about just treating a kidney stone. These are more complex sort of reconstructive surgeries to really improve patient's quality of life, but do involve a bit more of a recovery for patients.

Host: Which is why it's so important that we're discussing improving outcomes and discharge planning. So Mara, tell us about your approach to discharge planning for patients undergoing these complex procedures.

Mara Markzon, LCSW (Guest): Absolutely. I think the first thing they teach us in graduate school is to meet the patients where they're at emotionally. And this is really important to me because sometimes what the needs are that I think are important, don't necessarily match up with what the patients want to address. I prefer to meet them in person if possible, when they're in clinic, seeing Dr. Kielb or one of our other doctors here. But if that's not possible, I also can connect with the patients via telephone or email. And I think in the first meeting, it's really important to make that connection, to complete the assessment and also talk about post-op recovery and support as to what kind of family support and community resources these patients have for when they're recovering from their surgery. When necessary, we also can talk about things like going to a facility or a rehab center or getting home health care on board to see them in their house, if that's something that's an option. And two of the tools that I like to use when assessing patients are the PHQ9, which is a depression screening and then a Frail Scale. These two things helped me determine kind of where the patients are at physically and emotionally and what kind of help they'll need.

Stephanie Kielb, MD (Guest): To add to that. I think from my viewpoint as the surgeon, everything Mara does as our social worker really compliments what I'm able to provide for the patients. So I'm very good at being able to evaluate their surgical, their urologic needs, talk to them about the surgical expectations and recovery, but all of those other aspects of sort of their recovery, may not be something that as their urologist, I'm the most trained and skilled, to be able to address with them. So Mara really takes a lot of time to get to know them, like she said, emotionally, really assess their home situation and what their needs will be when they do leave the hospital, or where they go after their surgical procedure. So invaluable for our patients for really their optimal recovery.

Host: Well, it certainly is and a very comprehensive approach. So Mara, how has this approach improved patient flow, reduced hospital length of time, reduced hospital length of stay, time to discharge. Do you have any outcomes or stats you want to share with us?

Mara: So my position started as a three month pilot about a year ago. And the initial scope of this pilot was only going to be five of the physicians here in our clinic. That quickly grew from five to eight physicians, even during the three month time that I was doing the pilot. During the pilot I saw on average 38 patients a month. I think we're still about that now.

One of the outcomes that we looked at was reduced avoidable days that were attributed to the patients and families in the hospital. And we decreased that avoidable day from 3.8 days to 2.2 days in just that three month period of time. We also looked at the length of stay of these patients, of the physicians that were in the pilot. And we decreased the length of stay from 5.6 days to 4.2 days. Being able to evaluate these patients before surgery and emphasize post-op care and support and begin that discharge planning, I think is truly what made the pilot so successful.

Because the length of stay for these patients in the time that I've been here at Northwestern is drastically decreasing, which provides less time for the inpatient team to be able to create these safe discharge plans if it's only started once the patients have been admitted to the hospital. I think having the social worker begin these plans before surgery is invaluable. The team doesn't need to create the plan once the patients have arrived to the hospital and can confirm what I've already done, and it gives the patients an opportunity to research things on their own and go and visit these facilities and options before they come in the hospital. So they don't need to rely on their friends and family to do that for them.

Host: Well then Dr. Kielb, but how is it improving the clinical outcomes in urologic surgery? How does it benefit patients from your point of view? And is it similar to ERAS?

Dr. Kielb: So I believe it significantly improves their outcomes, because we all know that the hospital is not the safest place for anyone to be. I mean, we do everything we can to ensure patient safety. But it's an unusual environment for a patient to be in. Patients do not sleep as well in the hospital. They certainly don't eat as well in the hospital. And they recover much better when they're outside of the inpatient settings.

So all those things lead to improved outcomes for our patients. It definitely benefits the patients, but it also benefits their family. So the families have a very clear idea of the expectations that when their patients are discharged, what their needs will be after the surgery. And yes, I would make it comparable to ERAS. It is something that really helps patients get home safer and faster than they would have previously.

Host: I think this is the era that we're in now, and it's really so beneficial, as you said, Dr. Kielb, to both patients and to their families, but also to providers because it can help lend to better outcomes. So Mara, what resources are important to offer urology patients who are transitioning from the hospital to home?

Mara: I think every patient is so different and it's really dependent upon how the patient is at baseline before they come into surgery. How they're doing physically combined with what their support systems look like and what their resources are, both financial and otherwise. I think some patients have wonderful support systems that afford them the opportunity to recover in their own homes after surgery. Sometimes only with minimal support from the community or home health services, but other patients don't have that support and need full support and will transition to another care after the hospital. I think that as social workers rely heavily on our colleagues, both in social work and in rehab services, who can evaluate the patients once they come into the hospital, after they've had their surgery and see how they're doing physically and offer the patients tips and tricks on how to then go about recovering physically.

I think that while I do my best to try and start all these plans for these patients before they come in for surgery, sometimes things change postoperatively or something happens while they're in the hospital. Maybe the person they were relying on to help them no longer can help them, or something changes with their physical abilities. So I really rely on my inpatient social work counterparts to pick up where I've left off on the plans and keep working with these patients to create a safe discharge for home. And then they hand that back to me so I can continue to work with the patients once they come back to clinic.

Host: Certainly a multidisciplinary approach and Dr. Kielb, how can physicians help facilitate the discharge planning process?

Dr. Kielb: Well, I think it's important for us to really communicate with the patients, but also communicate with our social worker. I mean, I consider Mara kind of a partner on our team, really taking care of patients and getting them safely in and out of the hospital. So, communicating with Mara frequently. She comes to our clinics. We discuss patients. We discuss the anticipated surgery, we discuss their recovery. So, I mean, Mara has a pretty vast understanding of urology and urology surgery. She was our previously our inpatient social worker for urology. But not all social workers would have necessarily that background. So I think that communication is key in understanding what kind of surgery the patient will be undergoing and what the anticipated recovery is for those patients.

Host: I'd like to give you each a chance for a final thought. This is such a great topic. So Mara starting with you, what advice do you have for other institutions who are looking to streamline complex discharge planning? I mean, you started this pilot program at Northwestern Medicine. It's turning out to be successful with benefits and better outcomes. What would you like to tell them?

Mara: I think the first thing I'd like to say is to hire a social worker for your clinic. Dr. Kielb and I had been talking for many years about what kind of support I could provide to the clinic before I even came here. So I think that hiring the staff, the multidisciplinary staff that are needed for your clinic is really important.

Social work isn't a profession that brings in revenue to institutions, we're money saving. And I think that sometimes that's looked at a little differently. But decreasing avoidable days and length of stay and saving money is really important as well. I also think that there's a much larger focus on the social determinants of health. At least I'm seeing that here, and those are things that social workers can help address for the patients. I think a much more comprehensive care approach is able to be provided when you have these different disciplines in the outpatient clinics, because I can follow and continue to address the needs of the patients even after they're discharged from their surgery.

I think Dr. Kielb had mentioned previously that we just bring different skills to the table and look at these patients from different lenses. And I think it's important that we all are part of that team so that we can give a comprehensive approach to the patient's care. I think one of the other benefits has been satisfaction to the other providers in the clinic. There's things that I've taken off the plates of other providers, things that they could do, but maybe weren't in their scope of practice that I also then can do and take care of for these patients.

Host: Dr. Kielb last word to you. What would you like listeners to take away from the messaging about the importance of facilitating discharge planning, improving outcomes for complex urologic surgeries?

Dr. Kielb: Yeah, I would echo Mara had said. I mean, I think that there's a lot of talk out in the world these days about social determinants of health and health equity. And if we really want to focus on health equity, I think social workers are a key part of that. I mean, for instance, many of my patients come from the disabled population. Many of them have cognitive issues. Many of them come from a lower socioeconomic status at times. And really giving those patients the attention that they need, really looking into, how can we help those patients particularly do better, recover better, have better outcomes is something that's certainly near and dear to my heart.

And Mara's heart, but I think from an institutional level, if we're really committed to taking care of all patients, this is something that really should be at most people's clinics. And I would say many people's clinics or all clinics, to really help better take care of these patients. It's really been invaluable in the clinic.

Mara has really helped significantly. Our nursing staff, our nurse practitioners for many of the tasks that they were sort of outside their scope of practice. And they were more than willing to help us with, but what could be very time-consuming for them. And some other things that, that their skills were needed for sometimes they didn't have as much time for things. So the benefits of having a social worker in the clinic for us has been completely invaluable. And I know from my, particularly for my patient population, the congenital urology patients and the disabled population, spinal cord patients for instance, having a social worker in the clinic to help with a variety of things, not only discharge planning, but many other aspects of their care, has really improved their care and their outcomes and helped our clinic be more successful in caring for patients across the entire health spectrum.

Host: Thank you both so much for coming on and sharing your expertise on this really important topic and to refer your patient, or for more information, please visit our website at breakthroughsforphysicians.nm.org/urology to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. For updates on the latest medical advancements, breakthroughs and research, please follow us on your social channels. I'm Melanie Cole.