(l) PCP Christie Rivelli, FNP answers a question during a recent IDG meeting while hospice nurses Morgan Clemenhagen and Richard Holman look on.
Housecall Providers’ patients enjoy many benefits by having four integrated programs under one roof. One advantage is the opportunity to move seamlessly through an array of services designed to support patients as their medical needs change.
Another benefit is the quick and convenient relay of information between various members of the care team when there is a change in a patient’s health status. Whether a patient is sent to the emergency room, beginning palliative care or admitted to our hospice program, information flows freely so transitions are easier and health outcomes are improved.
PCP attends weekly hospice meeting
One example of this is the relationship that primary care provider (PCP) Christie Rivelli, FNP has with the hospice team. Since last summer, she has been attending hospice’s interdisciplinary group (IDG), the weekly meeting where members of the team: nurses, social workers, certified nursing assistants (CNAs), and chaplains have an opportunity to come together to discuss patient care.
Since hospice patients do not receive routine visits from their PCPs, Rivelli wanted to still stay involved in her patients’ care, if for instance, a condition not associated with their terminal illness surfaced and started to negatively affect their quality of life.
Continuity of care
“I think the benefit of attending IDG is that it brings a continuity of care to my patients,” Rivelli said. “If a patient has recently come onto hospice, I can contribute knowledge at the meeting that goes beyond what might be put in the chart notes. The same can be said for the information the hospice clinicians share should one of my patients be discharged back to primary care,” she continued.
A recent patient transfer illustrates the ease with which communication flows between the Housecall Providers clinical staff.
“Another PCP’s patient that had recently been on hospice moved to a home I work with so she was transferred to me. The hospice team helped me get to know the patient before I saw her, including her health status, as well as her psychosocial needs. I think this helped make her care and the move really positive,” Rivelli continued.
Closer connection with the hospice team
Although Rivelli has always had good working relationships with hospice nurses, attending the meetings has allowed for closer connections with other members of the team, including the Hospice Medical Director, Dr. Nancy Cloak, the social workers, CNAs and chaplains, each of whom contribute important aspects of patient care.
“Being part of IDG has allowed me to have a deeper glimpse into the spectrum of end-of-life care that Housecall Providers offers the community. The common thread I hear throughout all of our programs is ‘What else can be done for our patients?’” Rivelli said.
