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Jane Shivnan and Gina Szymanski, who transformed care

Jane Shivnan and Gina Szymanski, who transformed care

Bone Marrow Transplant with Heart

tarting four years ago with a simple question—What can we do better?—nurse managers Gina Szymanski and Jane Shivnan transformed the way patients with leukemias, lymphomas and several other types of cancer who receive transplants from the bone marrow and peripheral blood are cared for at Johns Hopkins.

With managed care nipping at their heels, the pair knew costs for the pricey BMT program needed trimming. Furthermore, patients were dissatisfied—not with Hopkins’ medical treatment, which they rated superb, but with the lack of continuity among their medical team during a prolonged, two-month hospitalization (which in itself seemed unbearable). Finally, a new Cancer Center was on the drawing board, so an updated model of care was in order.

Today, the revamped program the nurses conceived is recognized as a national model. Called IPOP (Inpatient/Outpatient), it not only improves the patient experience, but trims 20 days off the average 45-day hospital stay and $20,000 off the $100,000 to $200,000 cost of bone-marrow transplantation. The key to the approach is allowing patients to move back and forth between the inpatient unit in the Hospital and nearby homelike apartments as their medical condition warrants. Yet, despite the fact that they are in the midst of a body-battering treatment patients never feel fearful. Always with them in their apartment is their own personal caregiver—a family member or close friend who has been trained by the IPOP nurses. The apartments also are staffed around the clock, and patients know how to make immediate contact with their medical caregivers in IPOP.

In coming up with alternative living arrangements for these desperately ill patients, the nurses, working with oncologist Georgia Vogelsang, M.D., examined issues from every angle. Would they be placing too much stress on the friend or family caregiver who must learn to monitor temperatures and medications? How could the Hospital avoid shifting higher out-of-pocket costs for outpatient treatment to patients with families? And would the staff, already working with critically ill inpatients, accept yet another level of responsibility?

Meanwhile, as the two nurses worked to provide seamless transitions from one phase of BMT care to the next, Shivnan acknowledges,“we knew we were turning the program upside down. We weren’t just looking at cost and length of stay. We wanted to make sure we were really improving things.”

“There were billing issues, home-care issues, medical record issues, legal issues,” Szymanski adds. “Being bedside nurses was essential to understanding what could be tweaked, fixed, changed. I don’t think this is an idea that could have come from a higher administrative level.”

In the end, Szymanski admits that revamping care was economically essential to the very survival of the bone marrow transplant program. But the fact that IPOP cuts costs is by no means what she finds most gratifying. “The cost piece is gravy,” she says. “This is better care. This is something you can really feel good about.”

- Mary Ellen Miller