A NATIONWIDE CHILDREN’S HOSPITAL PUBLICATION | VOLUME 30 ISSUE 4 | FALL 2015

Everything Matters In Patient Care

Extending Care to the Community

IN PATIENT CARE | 1 Providing support for Community Development For All People’s Contents Fresh Market is just one of many ways Nationwide Children’s is caring for our community. Features Revitalizing Our Neighborhoods: Healthy Neighborhoods Healthy Families 5 by Kelly Kelleher, MD, Vice President for Community Health and Community Health Services Research and Rev. John Edgar, Pastor & Executive Director, Church and Community Development For All People Through the Eyes of Parents: Ohio Fetal Medicine Collaborative 15 by Becky Corbitt, RN, MSN, CNL, Fetal Nurse Coordinator and Rev. David Kuntz, MDiv., Fetal Medicine Spiritual and Family Care Coordinator

Articles 4 Expanding Our Thinking of Family-Centered Care by Linda Stoverock, DNP, RN, NEA-BC, Senior Vice President, Patient Care Services, Chief Nursing Officer 10 Serving Children Around the World by Christine Sander, MHA, Manager, Network Development and Jennifer English, Senior Account Manager, Marketing 12 Helping Our Families Be Fluent in Care by Valerie Huang, MA, CHI™, Program Manager, Interpreter Services and Jeanette Foster, MSW, LISW-S, Director, Social Work and Language Access Services 19 Delivering Best Medication Outcomes Outside of Our Walls by Chet Kaczor, PharmD, MBA, Director, Pharmacy Services 20 Investing in Our Children’s Futures by LaVone Caldwell, MSW, LSW, Director Health Equity and Jane Goleman, MD, Office of Health Equity 22 How Sid the Sloth Can Help Children During Dressing Changes by Vicki Von Sadovszky, PhD, RN, FAAN, Nurse Scientist 23 Hospice and Palliative Care: Reducing Patient Falls at Home by Laura Brown Rozcicha, MSW, LISW-S, Manager, Hospice and Palliative Care 24 Streamlining Registration to Improve the Experience by Buffy Storm, Supervisor, Patient Access and Tracy Burris, Director, Patient Access 26 The Role of the Financial Counselors at Nationwide Children’s Hospital by Todd Henry, Supervisor, Patient Access, and Financial Counselor 27 Safety Out and About by Andrea Morbitzer, Risk Management Safety Analyst and Jodi Mascolino, RN, BSN, CPN Risk Manager

Editorial Staff: Editor: Charline Catt | Managing Editor: Marcie Rehmar | Editorial Board: Adeline Cursio, Margaret Carey, Cindy Iske, Hollie Johnson, Jenna Merandi, Paul Seese, Nanette Spence, Sherri Watts, Danielle Worthington | Editorial Assistant: Rosetta Gordon | Editorial Support: Colleen Canty | Photography: Brad Smith and Dan Smith | Art Director and Designer: Lindsey Tobin

Pictured left: Open two days a week, participants can shop the Fresh Market for healthy foods, including fruits and vegetables. Read more about our neighborhood involvement on page 5.

2 | IN PATIENT CARE IN PATIENT CARE | 3 Expanding Our Thinking of Family-Centered Care Revitalizing Our Neighborhoods:

n May 2015, Dr. Steve Allen led our prescribed that cannot be fulfilled because Healthy Neighborhoods Healthy Families conversations around health equity. we may not fully assess a family’s capability Kelly Kelleher, MD, Vice President for Community Health and Community Health Services Research and Health equity addresses poor health to carry out the instructions given, such as Rev. John Edgar, Pastor & Executive Director, Church and Community Development For All People Ioutcomes that are greater in populations filling a prescription or avoiding asthma with severe and chronic poverty or triggers, when they do not have insurance or racial and ethnic minorities living with may live in a house with mold. violence, homelessness and uninsured residents, to name a few. Eliminating the barriers to health care for these vulnerable Embracing family-centered care populations demands that we become outside of our walls calls for nurses Linda Stoverock culturally competent and understand more DNP, RN, NEA-BC, to spend more time understanding of the barriers for our pediatric patients, Senior Vice President, each family’s unique situation. beyond individual patient issues to the Patient Care Services, broader issues. Chief Nursing Officer Embracing family-centered care outside An article published by Advances in of our walls calls for nurses to spend Nursing Science describes specific nursing more time understanding each family’s actions have the ability to influence and unique situation. By knowing people change the outcomes for patients receiving in the contexts of their lives, nurses care. The first step toward this goal is have knowledge of the effects of societal critical self-reflection and deepening discourses and institutional practices on the political consciousness toward actions. lives of particular individuals and families. Nurses should understand if their practices Nurses can impact policy, both institutional and actions come from libertarian or and public, to better partner with families egalitarian conceptions. The latter indicates for improved health care. In this issue of there is no social justice without equity Everything Matters: In Patient Care, you in health and no equity in health without will learn about many of our strategic social justice. We have to address the initiatives and partnerships which aim to social conditions that influence health help our disadvantaged children reach their and eliminate the artificial separations full potential. Nurses and other clinicians between medical concerns and social are vital to ensuring everyone receives issues. Occasionally, the term can be heard the same access to care. Family-centered “this is a social admission.” Reframing our care is not just a model for working with thinking to understand a child’s rights and an individual patient or family, but how need for us to intervene with the family we partner with families throughout the to access resources needed for care rather community ensuring that everyone matters. than judging is a more productive way to engage with the team and ensure the child Visit ANCHOR/Everyone-Matters to view has unbiased access to services and care. Dr. Allen’s talk on health equity. Another example includes when care is

4 | IN PATIENT CARE IN PATIENT CARE | 5 “Anchor institution” is the name given As an anchor institution on Columbus, to large organizations that are resident in Ohio’s South Side, Nationwide Children’s high-risk communities and participate Hospital, in conjunction with neighborhood in or lead neighborhood revitalization leadership, takes a comprehensive approach efforts. Most often, anchor institutions to neighborhood revitalization with the are ‘meds or eds,’ that is, medical facilities understanding that social and physical or universities. Such institutions with environments influence health and well- Developing and longstanding ties to the community often being. In alignment with its strategic goals, implementing invest in neighborhood revitalization for a neighborhood agencies and Nationwide variety of reasons. For example, a medical Children’s work to support community revitalization efforts in an integrated facility or hospital may hope to have a safer wellness and remove barriers to achieving fashion takes a neighborhood for employees and patients, best outcomes — through a place-based coordinated and respond to an ethical imperative to help initiative called Healthy Neighborhoods intensive effort on their neighbors, or reduce medical costs Healthy Families. the part of many, and through better health in the neighborhood. working with partners Efforts are typically consistent with the Healthy Neighborhoods Healthy Families with shared goals is overall mission and focused on addressing (HNHF) focuses on the revitalization of essential to success. specific community needs. the three surrounding zip codes, including 43205, 43206 and 43207. Modeled after successful programs across the country, the HNHF efforts are distinguished by: 315 • A focus on population and place – 43205 improving and integrating systems that 70 71 70 Denise Williams purchased her home in 2011 from the Healthy Neighborhoods Healthy Families Realty Collaborative. NCH support people where they live • Authentic engagement of residents – 43206 and together worked to transform the neighborhood, working with neighborhood residents A History of Partnership: Community one home at a time. 70 as partners to identify, understand and Development for All People address neighborhood needs Traditional revitalization efforts in neighborhoods As Nationwide Children’s and CD4AP increased their often begin when a community identifies a specific 104 • Strong relationships with the investments, additional partners stepped forward aspirational goal or need, whether it is to improve 23 neighborhood schools – addressing including United Way of Central Ohio, Franklin County community safety, help transform local schools or create needs where children spend much of Land Bank, The Affordable Housing Trust and the City 71 affordable and safe housing in a blight-free environment. 33 their time and receive the foundation of Columbus. Now more than $15 million has been 43207 Recognizing the desire for safe and affordable housing in that will help them succeed later in life invested to eliminate substandard housing and improve its surrounding neighborhood, the HNHF initiative was existing housing stock in the South Side community. • Strong community partnerships – 270 initially launched as a comprehensive housing initiative 270 working with nonprofit, government, in partnership with Community Development for All faith-based and community People (CD4AP), a faith-based organization whose organizations to develop effective mission is to improve quality of life for low and middle- CD4AP strategies to impact the health and life income individuals on the South Side. An organization outcomes of the entire community with a strong connection to the people of the targeted CD4AP serves the community through a produce Developing and implementing revitalization community, CD4AP brought important assets, as they market, community kitchen and free store which supports thousands of neighborhood residents each efforts in an integrated fashion takes a had prior experience redeveloping blighted houses year. By authentically engaging individuals and coordinated and intensive effort on the part in the neighborhood and strong relationships with families, CD4AP helps the Healthy Neighborhoods neighborhood residents. of many, and working with partners with Healthy Families initiative connect with the shared goals is essential to success. By working with an organization with a similar mission aspirations of the residents. This ensures that the Zip codes in the south side of Columbus, Ohio where Healthy Neighborhoods and goals, combining their strengths and shared vision, work is done not just for the people but with the Healthy Families operates people in the community it serves. Nationwide Children’s and CD4AP formed the Healthy Neighborhoods Healthy Families Realty Collaborative

6 | IN PATIENT CARE IN PATIENT CARE | 7 The result is improvements to more than 100 homes in the target area. The HNHF housing efforts, now titled Healthy Homes, have improved the neighborhood physically, helped create a safer environment, strengthened connections with residents, and provided a strong foundation to support future revitalization efforts and inspire new partnerships. In 2015, CD4AP and HNHF’s Healthy Homes, working in collaboration EDUCATION with the NRP Group, the Ohio Capital Corporation for Housing and Chase Bank, were awarded $11.7 million in tax credits to build new affordable housing units with job training space for the residents and community. WORKFORCE HEALTHY NEIGHBORHOODS SAFE & ACCESSIBLE DEVELOPMENT HEALTHY FAMILIES NEIGHBORHOODS

Provides Improvements for Current Owners Revitalizing Homes Builds Vibrant Communities AFFORDABLE HOUSING HEALTH & WELLNESS

Increases Home Ownership

Other transformative work to ensure children and Effective neighborhood revitalization efforts by hospitals families have well-rounded support includes a focus cannot be done in a silo, but it requires the engagement A Comprehensive Approach Nationwide Children’s has hired more than 250 on education and health and wellness through the of key community stakeholders and multiple partners. implementation of school-based and community The Healthy Neighborhoods Healthy Families initiative As the Healthy Homes housing efforts continued to South Side residents since 2012 and more than 540 programs in the HNHF zip codes. The initiative story is one that includes a history of engagement, progress, the Healthy Neighborhoods Healthy Families are employed throughout the hospital. In support delivers and supports programs that promote social and collaboration, partnership and a sincere commitment to initiative has evolved to incorporate efforts in other of these efforts, the HNHF workforce development emotional well-being through prevention programming improve overall community health and make a long-term important areas, complementing work that was already programming includes job preparation training and that teaches children self-regulation and coping skills as impact on the lives of children and families. HNHF aims taking place. To truly improve and integrate systems that access to opportunities through workshops and job well as programming that teaches children and adults to build an opportunity-rich community on the South support people where they live, Nationwide Children’s fairs. Nationwide Children’s has also partnered with about the signs of suicide. School-based programming Side of Columbus, producing positive health outcomes began to expand partnerships in the areas of education, Columbus State Community College on a program with Columbus City Schools also includes services to and creating viable pathways from poverty and despair to workforce development, health and wellness and safety. called FastPath, a program designed to identify, recruit and connect unemployed and underemployed adults address physical health via nurse practitioners, who hope and prosperity. One example of this focus in other areas is the hospital’s with technical and employability training that prepares comprehensively address the health needs of children goal to increase the number of employees hired from the them for in-demand jobs that can create pathways to and adolescents. These and other examples demonstrate South Side neighborhood. long-term careers. the hospital’s commitment to its neighbors and the importance of partnerships to improving the quality of life in the surrounding community.

8 | IN PATIENT CARE IN PATIENT CARE | 9 Serving Children Around the World Christine Sander, MHA, Manager, Network Development Jennifer English, Senior Account Manager, Marketing

s a leader in pediatric care, Nationwide Assessment Children’s Hospital aims to extend our When a physician, parent or caregiver sends an inquiry, International nationally ranked programs and services to our multi-disciplinary team immediately mobilizes to patientsA and families around the globe. With more than connect with the family, obtain necessary details for Services

N N / one million patient visits a year from 50 states and 41 Y evaluation and provide a recommendation on how best E E T U G U O M countries, we continue to be a health care destination R R L B to proceed with care. O O O / S L T Y U O A G for children worldwide. R G O G Y/ EM L The team includes a physician or nurse clinician, a ER H CO Y ON MORE THAN ONE MILLION social worker and a Welcome Center coordinator. The PATIENT VISITS ANNUALLY... Welcome Center coordinator works with the family FROM ALL 50 U.S. STATES & 41 COUNTRIES to obtain all necessary information and schedules the formal assessment call, typically within 48 to 72 As we continue to grow as a destination for pediatric care, hours from intial contact. An interpreter is on-site and Facilitation and Logistics our fully dedicated leadership, physicians and staff are participates in the call to ensure complete and accurate To help ensure the experience is seamless and appropriate, ready and equipped to support the unique needs of our communication. we account for all aspects of the visit including complete international patients who travel from far distances to The assessment process aims to understand the whole coordination of appointments and care, financial receive our innovative medical care and treatment. picture of the child’s condition to make the best possible resources and any individual needs of our patient and families. From arrival to a safe transition back home, our The program at Nationwide Children’s has two goals: recommendation (see Figure 1). goal is to offer care and support that fulfills each family’s 1. Assess requests for treatment from a clinical- If determined that a patient will seek treatment in unique needs. psychosocial-economic perspective to ensure that Columbus, we transition our focus to the logistical only appropriate cases are accepted. process of planning their stay. • Welcome Center Concierge Services: Our 2. Facilitate patient inquiries, assessments, and concierge services’ primary goal is to help families • Telemedicine Consultation: To ensure a logistics to make the process as easy as possible for in any and every way. The center facilitates the seamless transition of care back to the primary international patients and referring providers. support and needs of our patients and families. This includes every aspect of travel accommodations, referring physician, we offer a unique “after Figure 1: Assessment transportation and interpretation services. visit” solution. This consult can be done at any time during the care plan. In addition to our • Financial Information and Resources: We want convenient and direct one-on-one consulting and our families to focus on their loved one’s care. To communication, we also offer a translated written help ease the visit, we work together to provide a outline of the care plan. Clinical Administrative clear financial plan that is transparent and complete NCH Physician Support that Comprehensive quote before their arrival. Our commitment to our treatment will have positive impact (care & logistics) families is to provide a price quote for any service within three days of the request. “Whole chart” review Payment facilitation Establish goal for care while at NCH Coordination of consent Ensure necessary ongoing care is available in home country Psychosocial Ensure family has understanding of goal for care while at NCH For questions or additional information, please email [email protected] Ensure home setting is adequately prepared for providing necessary ongoing care Coordinate interpreter, transport, etc. Determine return plan for ongoing care 10 | IN PATIENT CARE IN PATIENT CARE | 11 “I’ve been working here 15 years. In the beginning, there was no interpreter services, it was just Deka Siad and myself. It was like the old west, we were blazing trails. These people that would have Helping Our Families Be Fluent in Care no voice – I remember this mother that would come to clinic, sit and just say yes to everything not knowing what in reality the doctor said. This mother had no voice. So when we started, we gave that Valerie Huang, MA, CHI™, Program Manager, Interpreter Services mother that power. ‘I’m here, I’m your voice, you can ask anything you want.’ Jeanette Foster, MSW, LISW-S, Director, Social Work and Language Access Services I am giving these people a voice.” recent project conducted between Interpreter other than English. Patients who cannot discuss their Carmen Veguilla, Interpreter Services Services, Social Work and Endocrinology health care needs in the same language as their medical assessed families’ telephonic access to care. Over providers tend to have poorer health outcomes. 60A families who spoke a preferred language other than English were identified. They were surveyed specifically A vital part of providing quality, safe health care is the about their telephonic access to care. One third of the accurate exchange of information between the patient families shared that in the past six months, they had and caregiver. Patient communication standards were the need to call with questions or concerns about their established by the Joint Commission in January 2011 care; however, they did not call due to the language recognizing the importance of communication. barrier. The families that responded to the survey saying Providing interpreter services for patients and families they reached out with questions or concerns generally is a federal requirement. Hospitals that accept federal asked children, family members or school personnel to funding are required to comply with Title VI of the make the call for them. In some cases, families went to Civil Rights Act of 1964, which prohibits discrimination the primary care center, emergency department or just based on race, color, or national origin. This necessitates waited until a later scheduled appointment, forgoing providing interpreters for patients who are not proficient care. In response to the survey, an interdisciplinary team in English and requires that we provide this service at was formed to address these specific concerns with the no cost to the patient. Similarly, the Rehabilitation Act new DIAL Interpreting Service now available to families of 1973, which protects the rights of individuals with who speak a preferred language other than English. disabilities, requires health care organizations to provide Caring for illness or injury in a family member presents effective communication for patients who are deaf or challenges related to navigation and access that are hard of hearing. intensified for families who speak a preferred language

Interpreting Services at Nationwide Children’s Hospital Nationwide Children’s Hospital is committed to safe care. We promote optimal communication with our families who speak a language other than English through our Interpreter Services. The scope of services ranges from in-person, video and phone interpretation to translation services and cultural brokerage/education.

The five most common languages spoken by our families are:

SPANISH More than 400 in-person On average, there are SOMALI interpreting sessions 4,000 monthly interpreting scheduled daily calls equaling over 39,000 minutes a month ARABIC

NEPALI Nationwide Children’s 23% 7.5% AMERICAN SIGN of all Primary Care of Emergency has served families LANGUAGE in more than Network patients Department patients 87 require an interpreter requested interpreters languages

12 | IN PATIENT CARE IN PATIENT CARE | 13 What is a Qualified Medical Interpreter? interpreter. The addition of this interpreting modality A Qualified Medical Interpreter is fluent in at least two will help health care teams provide more immediate Through the Eyes of languages and has knowledge of medical settings and access to interpreters for unplanned encounters and for practices, professional ethics and medical terminology. facilities that are more remote. Parents: Ohio Fetal Having an understanding of the culture of American healthcare and the culture of the non-English speaker helps interpreters provide insights into cultural Medicine Collaborative Becky Corbitt, RN, MSN, CNL, subtleties. While working with an interpreter, it might Tips for Communicating Through Coordinator, Fetal Nurse Rev. David Kuntz, MDiv., Coordinator, Fetal Medicine be noticed that sometimes interpreters speak when an Interpreter there is a pause in the conversation (consecutively) and Spiritual and Family Care sometimes they speak as staff or the family member is speaking (simultaneously). If the speaker uses clear and • Speak directly to the patient/family, not the interpreter. concise phrases, consecutive interpreting contributes to more precise messaging. However, it can be difficult for • Use plain, simple language and avoid multiple the interpreters to comprehend and communicate the questions at one time, pausing often. context of a message when the message is received in • Be patient. The interpreter may have to paint short segments. To reduce this risk, it is helpful for the word pictures of terms you use. provider to speak briefly with the interpreter prior to • If you are concerned that the interpreter has the session. not interpreted everything, ask the interpreter to do so. It is important for the interpreter to understand • Ask the interpreter to point out potential whether he or she is delivering bad news, explaining a cultural misunderstandings. procedure, or providing discharge instructions when • Confirm the patient/family understands the they begin a session. message. • Document the use of an interpreter – be Simultaneous interpreting is typically used in sign specific. language interpreting. It is often the best method for spoken language interpreting when the speaker is in a high emotional state and does not have the capacity to pause (e.g. mental health encounters, emergency situations). This can sometimes be perceived by the As our community has become more diverse, Interpreter providers as rude. To prevent this misunderstanding, Services’ goal is to be a consistent, reliable partner interpreters should inform the provider and the family in all our efforts. This will ensure clear and accurate that they will be using this modality. communication between patients and care providers. Other Interpreting Services Interpreter Services plans to contribute to a health care community where all families feel welcome, valued and Interpreting services can be delivered in various safe from preventable harm. modalities. The most common mode for interpreting services is on-site interpreting. Telephone interpreting enables the interpreter to deliver interpretation via telephone, which is most commonly used when the message being conveyed is simple and brief, especially Visit ANCHOR/Interpreter-Services for step by step when no on-site interpreter is readily available. Video instructions to schedule an interpreter interpreting is another form of technology for language assistance. Video interpreters work remotely with live video and audio feed so they can see the parties and the expressions of the speakers and the speakers can see the

14 | IN PATIENT CARE IN PATIENT CARE | 15 We can become so busy treating the baby that we forget to look through the eyes of the parents.

The nesting stage is very important for all so busy treating the baby that we forget We want people to mothers and fathers who are expecting a to look through the eyes of the parents. know that no family that comes through baby. Even though this pregnancy is taking It is important to meet the needs of the our program will on a different course, we still encourage parents based on their cultural and religious walk alone. parents to enjoy the moment. During this beliefs. We have multiple layers of support time, parents often call the Fetal Medicine services we can offer to our families such Clinic to ask last minute questions. While as our spiritual and family coordinator, parents mark off items on their to-do psychologists, social workers and child life list, the fetal nurse communicates and specialists. Often times when medical advice coordinates the care plan with the medical is given to families, they don’t know who to he journey begins when a pregnant “Did I do this to my baby? Why did this teams. The big day arrives and the baby is trust. They feel powerless and vulnerable. mother is referred to a maternal happen to me?” Other reactions may be born. Parents understand the plan of care The first step is to recognize a family in fetal medicine specialist by her anxiety, fear, anger and denial. Allowing that will occur after delivery. The team emotional and physical crisis and get them Tprimary obstetrician for a detailed level time for the mother and family to process makes every effort to allow parents to hold the services they need. Families want to 2 ultrasound. Imagine sitting there the information and ask questions is a their baby in the delivery room. Before feel empowered in making decisions for knowing something is amiss because the critical first step in building a supportive the Transport Team takes the baby to their baby. We want people to know that scan is taking longer than expected. The environment. The good old saying, “time Nationwide Children’s, the team gives the no family that comes through our program perinatologist walks in, sits down and starts heals all wounds” describes the journey family a chance to say goodbye. will walk alone. It is with great joy that we to point at the ultrasound screen. The through the shock phase. come to work each day. We consider it a Imagine sitting there The final stage for families is protecting. It knowing something physician explains there is something wrong humbling responsibility to walk with our The gathering stage occurs between finding is a natural instinct to protect one’s child. is amiss because the with your baby that requires further care at families in such a difficult place. out about the fetal diagnosis and learning scan is taking longer Nationwide Children’s Hospital after birth. We as caregivers sometimes lose sight of than expected. The referral is placed to the Fetal Medicine what it entails. Our contact information is family-centered care. We can become Clinic as part of the Ohio Fetal Medicine provided to our families to call for questions Collaborative at Nationwide Children’s. and concerns. During this time, we offer appointments in our multidisciplinary No matter how this news is broken, the Fetal Medicine Clinic. We try to coordinate psychosocial impact on pregnant mothers visits to meet the needs of our families. Fetal Diagnosis Grief Stages: and families often stuns them. Most Fetal medicine care is patient driven care. Most families who hear about the fetal diagnosis go through the stages of grief. There are many things that the care team families who hear about the fetal diagnosis The clinic provides the opportunity to can do to help. go through the stages of grief. We like to meet with various pediatric specialists to categorize this process into four stages: discuss fetal diagnosis, anticipated recovery Shock Gathering Nesting Protecting shock, gathering, nesting and protector. and potential outcomes. Our goal is for Parents find themselves in a Occurs between finding out Encourage parents to enjoy The final stage is protecting; It commences with the shocking stage. families to experience a seamless transition state of disbelief. Allow time about the fetal diagnosis the moment even though a very natural instinct for Here, parents find themselves in a state of from pregnancy to newborn care. After the for the mother and family to and learning what it entails. the pregnancy is taking a families. Make sure to disbelief. Time seems to stands still. No one consult, the fetal nurse coordinator takes process the information and The goal is for families to different course. Fetal nurse empower families in making is prepared for this. Families are oblivious the family for a tour of the Intensive Care ask questions. experience a seamless coordinates the care plan. decisions for their baby. transition from pregnancy to and numb to everything else happening Unit and orients them to hospital protocols newborn care. around them. Initial responses may include: and resources.

16 | IN PATIENT CARE IN PATIENT CARE | 17 Delivering Best Medication Outcomes Outside of Our Walls Chet Kaczor, PharmD, MBA, Director, Pharmacy Services

Pharmacists are medication experts; all pharmacists now graduate with a Doctor of Pharmacy (PharmD) degree and many continue on to receive residency training to further specialize. Our patients and caregivers deserve and need access to pharmacists to educate about medications, to ensure patients are taking the correct medications at the optimal dose and to assess adherence with medications.

Recently, two pilot projects at Nationwide Children’s have demonstrated that pharmacists’ or student pharmacists’ involvement in medication reconciliation can reduce the number of inaccuracies on discharge edications remain a cornerstone treatment medication lists given to patients and caregivers. of chronic disease states, both in adults and Furthermore, in select areas, patients can have their pediatrics. Children who have multiple prescriptions delivered to their bedside before they leave, Mdisease states are often asked to take many medications; ensuring access to medications. sometimes children take more than twenty different Nationwide Children’s is now the nation’s second busiest prescription medications per day in order to manage children’s hospital in the country and the vast majority their conditions. For a family who is preparing for Ohio Fetal Medicine Collaborative Team of the more than one million patient visits are outpatient discharge, there are many items requiring attention, clinic visits. As a result, pharmacy services are rapidly • Advanced Illness Management To learn more about Ohio Fetal including follow-up visits, dietary modifications and expanding in the outpatient areas. New pharmacist • Cardiology Medicine Collaborative: medical device maintenance and utilization, in addition positions have been added in the Complex Care Clinic, • Cardiothoracic Surgery to remembering to fill new prescriptions and how to Pediatric Epilepsy Center, and Cystic Fibrosis Clinic. • Clinical Genetics take these medications. In order to give families the best The Ohio Fetal Medicine Collaborative is the result These pharmacists will be integral members of the • Craniofacial Surgery chance at success outside of our walls at Nationwide of six widely acclaimed health care systems inter-professional team, working to ensure that we keep • ENT Children’s Hospital, we must start this transition inside coming together to achieve the common goal our patients well so they do not need to be readmitted • Maternal Fetal Medicine of providing high-risk expectant mothers and our walls. to the hospital. In addition to optimizing therapy and • Neonatology their babies with suspected fetal abnormalities ensuring comprehensive medication reconciliation, • Neurology A key to delivering best medication outcomes for all of the highest quality care in a family-centered these pharmacists understand prescription insurance • Neurosurgery our patients is getting more pharmacists at Nationwide environment. The participating hospitals include: formularies and help patients navigate the often complex • Nephrology Children’s to interact with more patients and caregivers. Nationwide Children’s, Wexner Medical Center, landscape of the prescription benefit. • Orthopedics Ohio Health, Mt. Carmel Health Systems, Dayton This is a core element of our pharmacy practice model • Pediatric Surgery Children’s and Miami Valley Hospital. redesign. The American Society of Health-System Overall, pharmacists help to ensure patients receive Pharmacists (ASHP), one of the leading professional • Urology Learn more at OhioFetalMedicine.org. appropriate medications at correct doses and assess the • Myelomeningocele team pharmacist organizations, sponsors the Pharmacy benefit of those medications. Our pharmacy practice • Fetal Nurse Coordinators Practice Model Initiative. As stated on the ASHP model is changing here at Nationwide Children’s with • Chaplain website, “the goal of this initiative is to significantly the goal of making more pharmacists accessible to • Social Work advance the health and well-being of patients by patients and the health care team as we strive to achieve • Clinical Psychology supporting futuristic practice models that support the best medication outcomes for all of our patients, both most effective use of pharmacists as direct patient care inside and outside of our walls. providers.”

18 | IN PATIENT CARE IN PATIENT CARE | 19 Investing in Our Children’s Futures LaVone Caldwell, MSW, LSW, Office of Health Equity Jane Goleman, MD, Office of Health Equity

he Office of Health Equity was created in Figure 2: Percent of Visits by Ethnicity September 2013 to help identify and eliminate January-June 2015 health disparities at Nationwide Children’s THospital. Dr. Olivia Thomas, Ambulatory Division Chief, and Rick Miller, Chief Operations Officer, 2% 2.2% 9.8% had a vision to add a new component to the quality 3.5% American and safety platform of the 2013-2018 Nationwide 3.7% Somali Children’s strategic plan. With an increased number of Mexican expanding interpreter and translation services, and families living below the poverty line and lead to patients and families traveling to Nationwide Children’s 78.9% Multi Ethnicity engaging employees in recognizing their stereotypes better health outcomes. from all walks of life, all over the world and all with African and biases different abilities, skills, experiences and cultural All Others 2. Building the capacity for health disparity research • Community Relations: developing programs to over the next year. This will increase the scope and backgrounds, we had to consider health equity as a key address issues affecting the social determinants of to ensuring best outcomes for all children. collaboration of health equity work across our health for patients living in poverty and supporting institution. At Nationwide Children’s, our work is Nationwide Children’s can be difficult to navigate for and collaborating with Healthy Neighborhoods all about improving the overall health and health minority patients and families, as well as those with Figure 3: Percent of Visits by Language Healthy Families care experience for all of our patients and our limited English proficiency (LEP). Variables related January-June 2015 Quality Improvement work addresses health equity by community. to racial and ethnic stereotyping and implicit bias identifying disparities and then creating interventions to can impact clinical decision making and create poor 0.7% close the gap and improve health outcomes. Collecting 3. Enhancing our patient experience by providing 0.8% 2.7% patient navigators, improving our collection and use communication. In addition, patients’ and families’ 3.3% good data lays the groundwork and allows us to look at lack of trust, poor adherence to treatment and delays outcomes by race, ethnicity, language, payer, etcetera. of patient satisfaction data and using focus groups to 5.7% in seeking health care can also contribute to health English In 2014, the Health Equity Data Enhancement better understand our patients’ perspectives. Spanish disparities. Team comprised of experts and leaders from various The Office of Health Equity is contributing to the Somali departments across Nationwide Children’s, updated the improvement of patient-provider communication, As you can see from Figures 1, 2, and 3, Nationwide 86.8% Arabic race categories and expanded the list of ethnicities. As a patients’ and families’ ability to navigate our health care Children’s is serving patients and families from very Nepali part of a nationwide pediatric health equity collaborative, system and the overall patient and family experience. diverse backgrounds. Over time, various departments All Others we are also working with other hospitals to establish Furthermore, we hope to eliminate stereotyping and guidelines for the collection of this data in pediatric biases that often lead to poor outcomes and patient Figure 1: Percent of Visits by Race settings. mistrust. In May 2015, Nationwide Children’s January-June 2015 and areas of Nationwide Children’s Research Institute We have begun to look at our data through the lens of introduced the Everyone Matters campaign to encourage have addressed topics related to health inequities. The race, ethnicity, language and payers across different areas staff to start new conversations and engage in new ways 1.5% 3.2% Office of Health Equity is an additional component of of patient care from asthma, adolescent care, behavioral of becoming more culturally aware and competent. The these efforts. Strategic priorities were developed by a ultimate goal is to create an internal culture that values 6.3% White health, child protection referrals, immunizations and team of physicians, senior leaders, clinical staff and other and embraces the highest standards of inclusiveness Black infant mortality due to unsafe sleep. In many cases, we 6.9% multidisciplinary leaders, and include: and health equity, celebrate the inclusive and diverse Latino have not found a disparity or gap in care, but in other areas, there is work to be done. nature of our staff and the patients and families we 55.3% Other • Data Collection: standardizing race/ethnicity/ serve worldwide and become a community leader in 26.8% Asian language (REL) data collection Future plans include: inclusiveness and health equity. Unknown • Quality & Safety: stratifying key quality measures 1. Establishing a medical legal partnership to help Visit ANCHOR/Everyone-Matters to learn more about by REL data and reporting identified disparities address some of the social determinants of health our efforts to address health disparities. • Patient Experience: enhancing the patient (e.g. housing, education, employment, health and experience and improving patient satisfaction, wellness), which will provide greater stability for

20 | IN PATIENT CARE IN PATIENT CARE | 21 How Sid the Sloth Can Help Children During Hospice and Palliative Care: Dressing Changes Reducing Patient Falls at Home Vicki Von Sadovszky, PhD, RN, FAAN, Nurse Scientist Laura Brown Rozcicha, MSW, LISW-S, Manager, Hospice and Palliative Care

omecare’s Hospice and Palliative Care teams 2. If there is enough risk, the RN notifies the Physical researchers also measured physiologic signs of pulse are making progress in reducing patient falls Therapist (PT) with a standardized handoff and rate and oxygen saturation. In addition, the length that occur outside of hospital walls. The requests an in-home fall assessment and education. of dressing changes was also timed. There were no HHospice and Palliative Care teams care for 55 patients significant differences in baseline characteristics between 3. The team created a home assessment tool which the whose desire is to remain out of the hospital despite the two groups prior to the intervention. PT completes in the home with the family. The PT terminal or life-limiting conditions. The program cares provides insight into high risk actions (i.e. a parent The nurse researchers found that the children’s for patients with a wide range of diagnoses from cerebral carrying a heavy child upstairs or a parent lifting a perception of pain in the video game (intervention) palsy to hypoxic-ischemic encephalopathy to cancer. teenager alone). The PT offers education and safe group was reduced by 42% compared to children in Due to their diagnoses or declining conditions, many of alternatives and recommends equipment to help the control group, which is a statistically significant our patients are at high-risk for falls in the home or out ensure those safety measure are attainable. difference. Parents’ (visual analog scale) and nurses’ in the community. Serious falls can lead to injury and 4. The PT brings the report and equipment (FLACC) ratings of pain of the intervention group unwanted suffering for our patients. recommendations back to the Homecare and were also significantly lower compared to those of In 2013, the team noted the frequency of at-home falls Hospice team who then works on getting the the control group. While oxygen saturation was not being reported by patients or parents was concerning. equipment ordered and implemented in the home ne of the hardest symptoms for us to deal with significantly different between the two groups, pulse We have non-ambulatory patients, some weighing environment. If the PT needs to do a second visit for as health care professionals is pain, especially rate was significantly lower in the intervention group. over one hundred pounds, whose parents carry them any reason, the nurses provide notification. during a procedure. A patient’s perception of Another benefit of using the video game intervention upstairs to bed at night. We have independent teenagers, Opain requires the use of attention, so some nurses are Since implementing the program, we have seen a was an average five minute decrease in length of time for whose cancer has progressed, who make their way now testing the effects of distraction through virtual the dressing changes, which is a significant difference in significant increase in the number of days between to the bathroom because they want to maintain that reality, such as video games, on children’s attention to or the intervention group compared to the control group. reported falls in the home and community (see Figure independence. Both scenarios have resulted in potentially perceptions of pain. The conclusion was that virtual reality distraction was 1). Although we have not hit our target of zero falls in dangerous falls for our patients. We wondered how these an effective non-pharmacologic measure to alleviate the the home, we are pleased that falls have become less A group of nurses in a large Chinese pediatric hospital falls could be prevented while respecting the autonomy perception of pain during dressing changes. frequent, that our Zero Hero awareness of fall risk for tested the effects of using a video game on the pain of the patients and families we support. We knew this our patients has increased and that we have a plan to of children ages 4 to 16 years during dressing changes Virtual reality modalities are becoming popular methods was a Zero Hero opportunity. offer our patients when we find they are at risk. on wounds in a randomized controlled trial. The for patient care and education. Currently at Nationwide Pulling together our Homecare and Hospice resources, wounds were obtained primarily through injuries and Children’s, there are at least two groups of nurses Days Between Falls in the Home for NCH Hospice we collaborated with our Quality Improvement & Palliative Care Patients at least half of the wounds had sinus tracts. Children working on virtual reality projects for patient care. Coordinator, Kelly Kersey, and Homecare Physical in the intervention group were given an Ice Age 2: The 300 If you have an idea or would like to assist with Therapist, Andrea Bradley. From a literature review, we Meltdown game and asked to help Sid the Sloth slide 250 these projects, please contact Vicki Von Sadovsky at found that there is very little information about how to down a snowy path to collect acorns and avoid obstacles. [email protected]. 200 help prevent falls in the pediatric hospice or palliative 135 Calendar Days Children in the control group were given the usual care Without a Fall care population at home. We were up to the challenge of 150 of toys, television, books or parental comforting. creating a plan ourselves! Along with our team’s nurses, 100 Perceptions of pain were measured three different we created a four-step plan we hoped would work. Baseline ways: 1) the patient’s perception using the FACES scale Calendar Days Since Last Fall 50 1. RN in-home fall risk assessment, including: (picture scale for self-report of pain), 2) the parent’s 0 • Is there a history of falls? perception using a visual analogue scale, and 3) the • Is the patient ambulatory or carried by a parent? 01/17 01/31 02/20 03/12 04/23 05/06 11/04 07/28 08/13 11/22 12/29 05/13 nurses’ assessment using the FLACC (Face, Legs, 2013 2014 2015 • Has the patient’s condition changed in a way that Date of Event Activity, Cry, Consolability behavior scale). The nurse could impact safety while ambulating? Have you had a good catch regarding falls? • Is the patient taking medication(s) which could Let us know what you are doing for inpatients, outpatients impact safety while ambulating? and at-home patients by reporting your good catch at ANCHOR/Manager-Scorecard---Good-Catch-Stories.

22 | IN PATIENT CARE IN PATIENT CARE | 23 This self-check-in kiosk process in the Crossroads area their first appointment of the day and to check in at Streamlining Registration to Improve has assisted the Patient Access Staff to efficiently manage the clinic desk to let them know that they have arrived. the high volume of patients by reducing the number When a patient/family checks in at the clinic desk, the the Experience of full registrations that are needed to be done with a staff member within the clinic then flags the patient Buffy Storm, Supervisor, Patient Access representative. This full registration process is more time in the computer to an “arrived” status and collects any Tracy Burris, Director, Patient Access consuming and lengthy which then delays the families clinic-specific forms and information required for the in arriving to their appointments on time. Families have visit. This process alerts clinical staff to the arrival of been able to quickly adapt to the user-friendly kiosks and the patient to the specific clinic so that the patient care enjoy the self-directed system and timeliness that these process can commence. kiosks are able to provide in getting them checked-in and to their appointments more efficiently. This centralized registration process has been possible through the combined efforts of several individuals So how does this process work from a and departments acting together as one team. Together clinic perspective? and through a commitment to constant improvement, After successfully registering a patient for their we have successfully begun to change the way we appointment(s) within Crossroads Registration, either meet patient and family needs during the registration with a Patient Access Representative or through use of experience. a kiosk, patient labels automatically print in the clinic Because of the success of centralizing the registration where the patient will be seen for their visit. This helps processes, we have plans to open two additional to alert clinics that the patient has been registered for centralized locations by early 2017. their appointment. Families are instructed to travel to

hen patients arrive at Nationwide Children’s By creating one central location for registration of these for any tests or appointments, they must clinics, families with multiple appointments occurring first complete a registration process within throughout the day can now register for all of those Epic,W the electronic medical record. This includes the appointments in one easy step. This helps to decrease the collection of demographic and insurance information as amount of times that families need to repeat information well as obtaining proper consent for treatment. in their visit, as well as reduce the need for families to provide insurance cards and photo identification Families often see these tasks as tedious and time multiple times throughout their day. consuming because their first priority is to quickly get their child to their scheduled appointment. It is essential One of the highlights of the Crossroads Registration area that we gather accurate and complete information on is the implementation of the self-directed registration patients and families to ensure we are compliant with through our kiosk units. There are currently four HIPAA regulations and provide accurate and complete registration kiosk stations located within the Crossroads billing to providers. area. Families that have completed a pre-registration process over the phone, which includes the verification of At Nationwide Children’s, we are agile and innovative. certain information prior to their appointment, are able As such, the Crossroads Registration area was opened to complete their own registration quickly and efficiently in fall 2014. The area was developed with the goals of through these kiosks. streamlining patient registrations and creating a better customer experience.

24 | IN PATIENT CARE IN PATIENT CARE | 25 The Role of the Financial Counselors at Safety Out and About Nationwide Children’s Hospital Andrea Morbitzer, Risk Management Safety Analyst Jodi Mascolino, RN, BSN, CPN Risk Manager Todd Henry, Patient Access Supervisor, Financial Counselors

his is an opportune time for employees to reflect • As you walk toward your location from your vehicle, mong the many great attributes of the clinical The counselors are also available to offer education about on practices and behaviors that contribute to watch where you step and look for loose flooring, staff at Nationwide Children’s Hospital, two the hospital’s financial assistance programs in order to a Zero Hero safety culture. Approximately 332 bad stair steps, snow and ice. of them really make our staff stand out: the facilitate an application to these programs as quickly TNationwide Children’s employees provide services in • Are there signs of impending violence such factA that they are incredibly proactive, and that they are as possible, and they work closely with Registration the home and other community venues where they can as verbally expressed anger and frustration, profoundly family-centered. In an effort to mirror this staff to minimize coverage errors and to identify the place themselves at risk when they face an unpredictable threatening gestures, signs of drug or alcohol abuse, level of commitment and service to our patients and under-insured who arrive for treatment. Recently, in environment by entering a patient’s home. or the presence of weapons? their families, Patient Access Management introduced an effort to enhance the possible options to ease the the role of financial counselors to the hospital system financial burden of medical treatment, the financial What prevention strategies can home based and – Leave the patient’s home and notify your in the spring of 2014. Since that time, the financial counselors have begun to pilot programs to estimate homecare employees use to create safer workplaces in the supervisor. home and community? counselors have become an integral part of Patient Access out-of-pocket costs for surgical procedures and assist in While at your location, keep an open pathway for and the hospital and are striving to emulate the best securing pharmaceutical rebates for some of our patients’ exiting. qualities of the clinical team in order to achieve the best prescribed medications. • If you encounter hostile and aggressive individuals results possible for our families. The financial counselors believe that by using a variety during a patient visit, defuse anger with a Whether it’s a new mom who recently moved from of tools to solve a family’s financial concerns, they can composed and caring attitude, calmly bring closure out-of-state, a critically-ill young adult who is too embody the proactive and family-centered approach that and leave. sick to work, or a non-English speaking family at a is so engrained within the clinical staff at Nationwide • If you need to call 911, do it. well-baby visit, those who lack the financial means Children’s. Always available by phone at (614) 722- • Report any incidents to your supervisor, no matter to confidently cover the cost of their medical care are 2070, Vocera, or email at FinancialCounselors@ how minor, and discuss what needs to be entered always the top priority of the financial counselors. The NationwideChildrens.org, please do not hesitate to into CS STARS. stated mission of the counselors has always been to help contact financial counselors if you have any questions those patients who lack the financial ability to cover about how we can help you help your patients. Workplace safety is everyone’s responsibility. You can the cost of their visits. The thought behind this is that reduce employee preventable harm in simple steps. families who are insured are more likely to schedule and Always let your supervisor know your location and attend follow-up visits, fill prescriptions, etcetera. With schedule. Park your vehicle in a well-lit area. Keep health Assess the manner in which you operate your motor this in mind, the counselors meet or contact patients care equipment, supplies, and personal belongings vehicle. visiting any of our locations, many times even before locked out of sight in the trunk of the vehicle prior to • Are you distracted and/or fatigued when you drive? their scheduled appointment. To date, mainly with leaving home. Plan to bring only the items necessary the use of a temporary form of Ohio Medicaid known • Do you use your seat belt? to patient care. Minimize the possibility of forgetting as Presumptive Medicaid, the financial counselors • Are you prepared to drive in poor weather personal items or your chances of relocating unwanted have secured coverage for over 5,000 patients and conditions? critters to your home. Before getting out of the car, their siblings either before or during their visit to the check the surrounding location and activity. If you feel • Is your vehicle properly maintained? hospital, which usually relieves the burden from parents uneasy, do not get out of the car. Trust your judgment. If or guardians with other things on their mind, thereby • Do you follow the rules of the road? it doesn’t feel right, it probably isn’t. allowing them to focus on their treatment plan rather Engage in good practices when you arrive at your than on their most recent financial statement. By relying on prevention safety strategies and paying location. attention to your instincts, you will increase your ability • Are there strong odors from a drug lab, gunshots, to reduce preventable harm and focus efforts on being a shouting and/or sounds of fighting? successful Zero Hero! – Stay in your car and contact your supervisor if For additional safety tips, like how to avoid you notice anything that might threaten your needlesticks, back injuries, falls and bodily fluid security. You may need to drive away. exposure, visit ANCHOR/Focused-Efforts.

26 | IN PATIENT CARE IN PATIENT CARE | 27 NONPROFIT ORG. U.S. POSTAGE PAID COLUMBUS, OH PERMIT NO. 777

Nationwide Children’s Hospital 700 Children’s Drive Columbus, Ohio 43205-2696

Daisy Award Wendy Charles, RN

The tenth Nationwide Children’s Hospital Daisy Award was awarded to Wendy Charles, RN, a Homecare nurse who previously worked on an inpatient unit. The Daisy Award is given in appreciation of the important difference our nurses make in the lives of the patients and families at Nationwide Children’s.

Wendy was nominated by Holly Deem, a fellow nurse, for her dedication to her patients and families. “I was deeply touched by Wendy’s efforts to educate one of her an amazing job putting together the asthma care plan asthma patients. Wendy recognized this patient’s realities at her patient’s educational level. She tried to make sure at home. She wanted to make sure her patient could do the patient was going to be as safe as she could be in her what she needed to when she went home and Wendy did home environment.”

EVERYTHING MATTERS: IN PATIENT CARE, previously published as Heartbeat, is a quarterly publication of the Patient Care Services Division of Nationwide Children’s Hospital, Inc., Columbus, OH. Comments regarding the content of this publication are welcomed. References for articles are available by calling (614) 722 -5962. Articles may be reprinted with permission. Send all inquiries and material for publication to EVERYTHING MATTERS: IN PATIENT CARE in care of Rosetta Gordon, Administration, Nationwide Children’s Hospital, Inc., or call (614) 722-5962. Nationwide Children’s Hospital is an affirmative action, equal opportunity employer. Copyright 2015, Nationwide Children’s Hospital, Inc. All Rights Reserved.

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