of the Year

with Care Oregon that facilitated the development of
"hot spot teams", an interdisciplinary group of health
care professionals that support these patients with
frequent contacts, regular follow-up and home
visits. Recognizing that Oregon's case mix index for this
group of patients exceeds that of other states
significantly, she has also focused her efforts on creating
a support system for our lesser acute patients who still
possess multiple risk factors and complex needs.
Prior to discharge, Jayne insures that all patients are
provided a personal scale for use at home and that they
understand the importance of trending their daily
weight. This important addition to the discharge process
was recently featured in an Associated Press news release
that described her new plan for her patients as “Learning
by Doing”. She has made available to non-English
speaking patients discharge instructions in their native
language, and she continues to work tirelessly on
improvements to the After Visit Summary. Through her
efforts with nursing staff, she has standardized teaching
instructions and documentation, and established a clearly
understood standard of care that all of OHSU’s CHF
patients now receive.
In addition to these efforts Jayne also recently procured
ten "Health Buddies", telemedicine type devices that
prompt patients to enter daily information about their
health while also challenging them to a trivia game.
When abnormal parameters are detected by these
devices, a call is immediately generated to Jayne, so that
she can follow-up immediately with the patient and
perhaps reverse a trend that might be moving in the
wrong direction. She is currently providing these to 10
discharged CHF patients per month to discover their
impact on improved outcomes and possible decreased readmission
rates.
Most recently, this work was featured at the Robert
Woods Johnson event "Care About Your Care“ in
Washington DC. Meeting with health care leaders from
across the country, Jayne and the Oregon contingency
received accolades and repeatedly heard the phrase that
"things were more progressive and different in
Oregon". Different yes - our current all-cause readmission
rate for CHF patients is averaging about 17%
when rates from similar institutions nationally average
nearly 22%. This is a testimony to the health care
transformation that Jayne is leading for our CHF patient
population - and also to her exemplary level of dedication
and professional practice that establish her as a leader
within her field.
“Jayne is one of the most ‘get it done’ and positive
colleagues I have had the pleasure of working with. Her
caring for patients and quest to improve quality is deep and
inspiring. She is an outstanding APN in all components of
the professional nursing role.”
Ann Maylie, RN, Division Director