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The Sunday Conversation
Sun September 29, 2013
'Navigator' Helps ER Patients Who Don't Need Emergency Care
Originally published on Sun September 29, 2013 10:22 am
Each week, Weekend Edition Sunday host Rachel Martin brings listeners an unexpected side of the news by talking with someone personally affected by the stories making headlines.
Wendy Shindler, a nurse, works in the waiting room of New York City's Montefiore Medical Center's emergency department, where she identifies patients waiting for services who don't actually need emergency room-level care. The program is an intervention aimed at improving care at the busy Bronx hospital while reducing costs.
"The ER was admitting everybody, and they weren't getting paid — Medicare wasn't paying them for everything," Shindler tells NPR's Rachel Martin. "And they said, we have to figure out a way to help the community so they can stay out of the hospital." So, Shindler, who had ER and case management experience, became the hospital's patient navigator.
Not everyone was on board with the change at first. "The doctors in the emergency room, they were concerned because they thought they needed to admit everybody," says Shindler. Obviously, there's a liability concern when a patient with chest pains is referred to a cardiologist the next day, instead of being admitted.
"What I did was, I gave them feedback from the cardiologist the next day," says Shindler, "and said, 'Listen, the patients did go and they're getting good care and they're doing OK in the community.'" And, she points out, the patients were happier, too.
After about a year and a half, the doctors came around. "I still remember when they said to me, 'Wendy, you're part of the team. You made it. We see what you can do for us.'"
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WENDY SHINDLER: This job is so amazing because I'm advocating for the patients. I'm like a GPS system - I go north, south, east, west - and I figure out a plan for the patients.
RACHEL MARTIN, HOST:
That is Wendy Shindler. She's an emergency room nurse at Montefiore Medical Center in the Bronx. Most of the patients there are on Medicare or Medicaid and the emergency room is among the busiest in the country, which is why the hospital gave Wendy a different kind of nursing job. Instead of treating patients for whatever brought them into the E.R., her job is to turn patients away and direct them towards the right services somewhere else.
It's something hospitals around the country are trying to replicate, as they strive to meet new standards established by the Affordable Care Act.
Wendy Shindler, an E.R. nurse from the Bronx, is our Sunday Conversation.
SHINDLER: What happened was the E.R. was admitting everybody and they weren't getting paid. Medicare wasn't paying them for everything. And they said we have to figure out a way to help the community so they can stay out of the hospital. And so, they said let's get a patient navigator, someone that can assist, that has the E.R. experience, that has the case management experience and can navigate the system for these patients.
MARTIN: How was that idea received? Was everyone on board with this - the medical staff, doctors, nurses?
SHINDLER: (Laughing) Ah, that's a very good question. Unfortunately not in the beginning because the doctors in the emergency room, they were concerned because they thought they needed to admit everybody. You know, if you have something on your CAT scan, what do you mean we're going to discharge them to a G.I. doctor tomorrow? It was a learning process. It took about a year and a half, to be honest, a year and a half till the doctors came around.
And I still remember when they said to me: Wendy, you're part of the team. You made it. We see what you can do for us.
MARTIN: This had to be a cultural shift because as caregivers, your instinct is to provide care to whomever comes through the door. And this program forced you to think differently.
SHINDLER: Right. Right. Right, that's the whole concept. You know, they thought they have to admit everybody. And my idea of you have chest pain and your blood levels show that nothing, thank God, is going on. You're not having a heart attack or anything, let's get you to a cardiologist the next day. The E.R. was like shocked by that: What do you mean we can discharge patients? You know, it's a liability for them - they think that everybody has to be admitted.
What I did was, I gave them feedback from the cardiologist the next day and said, listen, the patients did go and they're getting good care and they're doing OK in the community. And so, by me following up they realized the patients are getting the proper care in the community. And they're not coming back, and the patients are so much happier.
MARTIN: What is so hard about doing this? I mean, your hospital was kind of ahead of the game. But why is this so challenging for hospitals to replicate?
SHINDLER: You know what? It's challenging for a hospital to see, you know, something change. So I think hospitals are nervous about it because they don't want to boot somebody out and, God forbid, something happens to them that night. And so it's a scary challenge. Montefiore took the risk and they've really been successful with it, but it is challenging.
MARTIN: What percentage of the people you see in the emergency room do you turn away - or find alternative care, rather?
SHINDLER: Right now, I've diverted - last year, I diverted over 1500 patients from the emergency room.
MARTIN: Do you ever get pushback from patients who say, no, no, no - I need to be in the emergency room?
SHINDLER: Of course, yes. You know, they go, oh no, no. I don't feel well, I don't feel well, Please, keep me, keep me. And I have to help them. I have to say, no, it's OK, we're going to get you to your doctor tomorrow. I actually had a patient yesterday who lives alone and is having more increased dementia. And so she's like, I can't go. I can't go. I can't be by myself tonight. How am I supposed to do this? And I called the home care agency and I finagled and I asked the home care agency, please, can you get her someone for the evening? And we work, you know, it takes time, it has to work with the insurance company. But as long as they have a plan and they know that it's going to be OK, then they can go home.
MARTIN: This kind of work has changed the way you invest in your patients, it sounds like.
MARTIN: You're investing in their personal lives a lot more.
SHINDLER: I really am. I get involved with my patients. I actually had a patient once who had cancer and she was so scared to go to the doctor that I actually took her... (Laughing) ...to the oncologist myself and sat with her through her chemo treatments, and sat with her the night before she died, and we laughed and had ice cream together. I get involved in their lives. I care so much about these patients.
MARTIN: Is there someone who you've had to refer to a primary care physician, or some other form of care that you wondered about? You wondered if that was the right call. Did you have doubts? Did you wonder what happened to them?
SHINDLER: You know, it's twofold. I'm nervous about the patients are not going to go to the primary care. And then once they get to the primary care, do they know what to ask? I do know that there are some patients out there that I give them an appointment and I know they will never follow up. And I get scared for them. And I'll call them and I'll say, what's doing? How are you feeling? Oh, I'm fine, I'm fine. Thank you.
And I'm, like, please follow up. Go to the primary care. Go to your cardiologist. It's hard for them in the Bronx. They're working-class people and they and, you know, they have to provide for their families and they sometimes put medical care on the back burner.
MARTIN: Wendy Shindler is a nurse at the Montefiore Medical Center in the Bronx. Thank you so much for talking with us, Wendy.
SHINDLER: Thank you so much. Thank you.
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MARTIN: Tomorrow on MORNING EDITION, NPR's Julie Rovner answers some practical questions about the Affordable Care Act, how it works, who is eligible and where to go if you need help signing up. Not to mention, how much could coverage under the new exchanges cost you and your family? You can get the answers by using the Kaiser/NPR online calculator. Check it out on Shots. That's NPR's health blog at npr.org.
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MARTIN: You're listening to NPR News. Transcript provided by NPR, Copyright NPR.