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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
“Mrs. J was a patient that was being admitted at least monthly for almost a year. Jayne got involved, made home visits, arranged for home health nurse to see the patient weekly, worked with the Richmond Clinic and the nurses there, and worked with Care Oregon and the 'hot spot team'. Over months Jayne and her team was able to build trust with the patient and her family, identify triggers for readmissions and create a plan in response to those triggers. Over the course of months Mrs. J's readmissions were fewer and farther apart, her quality of life and her relationships with her children greatly improved. Jayne was able to change the trajectory of disease for this individual though her constant presence, sense of humor and belief in her ability to be successful. Jayne has taken what she has learned from working with individual patients and has created a system response to helping manage these patients. She has initiated a team of providers who meet monthly to create ways to increase the quality of care patients with end stage heart failure experience. Through her leadership, the readmission rate for heart failure patients has significantly decreased, they are being seen by their PCP within a week of discharge, and she has initiated an at-home telemedicine program where she monitors these very fragile patients daily for a month. Through her research, she discovered that the impact of home telemedicine decreases after a month. Jayne has worked with nurses throughout the organization to improve the education that patients with heart failure receive, a standardized approach is now utilized including documentation, provision of equipment patient's need to monitor their own response to therapies. Through her efforts with the nursing staff throughout the hospital there is decreased variation in practice from unit to unit and increased quality of care provided, Jayne exemplifies the advance practice role, clinician, leader, change agent, and transferor of knowledge every day in her practice. She is a role model for advance practice nursing.” Mary Denise Smith, RN, Palliative Medicine and Comfort Care
Page 1 and 2: OHSU Nurses Week Innovation. Compas
Page 3: Jayne Mitchell, ANP-BC Nurse Practi
Page 7 and 8: “I have always been a critical th
Page 9 and 10: “When Maki was on the floor, I kn
Page 11 and 12: “My esophagectomy patients (I cou
Page 13 and 14: he had about getting back on his fe
Page 15 and 16: Kathryn Conway, BSN, RN RN, 7A Trau
Page 17 and 18: her management of where the two int
Page 19 and 20: I am humbled to receive this honor.
Page 21 and 22: “I always knew I wanted to have a
Page 23 and 24: “Rhea is consistently gentle and
Page 25 and 26: (continued) feelings while also set
Page 27: DISTINGUISHED NURSE: Kathryn Conway

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