Patti Virga

Patti Virga is a registered nurse (RN) and a manager in Case Management at Mary Washington Healthcare. She began working as a nurse in the ICU at Mary Washington Hospital in 1990 and transitioned to case management in 1996.

Patti Virga was interviewed by Jess Rigelhaupt and Abigail Fleming on March 19, 2015.

Discursive Table of Contents

00:00:00-00:15:00
Decision to become a nurse—Became a registered nurse (RN) in 1984—Started at Mary Washington Hospital in 1990—Prior work experience—Comparison between working at Mary Washington Hospital, a community hospital, and a teaching hospital with interns and residents—Description of a “typical day”—Began working in the Case Management Department in 1996—Work experiences with insurance companies

00:15:00-00:30:00
Community resources—Working with patients who are homeless—Cultural diversity—Hospice—Palliative care—Definitions of a healthy human being

00:30:00-00:45:00
Social issues in medicine—Ethical question concerning health care as a right or a privilege—Job interview at Mary Washington Hospital in 1990 and first work experiences—Core values and mission of Mary Washington Hospital—Working as a nurse in the ICU—Discussions of the new hospital as it was being planned and built

00:45:00-01:00:00
First shift in the new hospital (1993)—Cardiac surgery and neurosurgery—Teamwork in the cardiac surgery program—Organizational change—Working relationship between nurses, physicians, administrators, and the board—Clinical skills—Patient assessment—Patient care—Decision to leave the ICU and work in case management

01:00:00-01:15:00
Responsibilities in case management—Continuum of care after patients are discharged from the hospital—Insurance companies—Medicare—Working relationship between case management and physicians—Hospitalists

01:15:00-01:26:51
Stafford Hospital—Moss Free Clinic—Interdisciplinary teamwork—Description of good days and positive experiences working in the ICU and in case management—Educating patients about resources—Summary discussion of working at Mary Washington Healthcare

Transcript

00:00:05
Rigelhaupt:
It is March 19, 2015. We are in Fredericksburg, Virginia, at Mary Washington Hospital doing an oral history interview with Patti Virga for a Mary Washington Healthcare Oral History Project. Two interviewers: Abigail Fleming will start off and my name is Jess Rigelhaupt and I will come in later. Abigail I’ll let you get started.

00:00:27
Fleming:
I’m just going to start off with some general questions about coming to Mary Washington and some of your experiences here. So, first off, what made you want to become a social worker? Actually a nurse. My bad.

00:00:42
Virga:
I think at the time, in 1982, it was one of the options that women graduating out of high school would go in to. I was raised in a small community and I went to a small private school. The senior class was only about sixty-two students and there weren’t a lot of options at that time. At least not a lot we were aware of. Nursing was one of the choices that I had made.

00:01:12
Fleming:
You said you worked at Fairfax Hospital in 1984, but then you moved down to Mary Washington Hospital. Why did you come to Mary Washington?

00:01:24
Virga:
The commute. When I first moved here from New York, I had no idea how far Fairfax was with the morning commute. I came from a large hospital in New York, a teaching hospital. I gravitated toward a teaching hospital coming to Virginia, not realizing the difference with the community hospital and living closer and having more of that community feel once I did come to Mary Washington Hospital.

00:01:52
Fleming:
Why did you come from New York to Virginia?

00:01:55
Virga:
My husband had a different job opportunity in Washington and that precipitated our move down here.

00:02:03
Fleming:
What first struck you about the teaching hospital and the community hospital? What were some of the differences you saw?

00:02:10
Virga:
The biggest difference is the interns and residents. You always have a lot of staff. There’s a lot of teaching going on. Students are always around. When you come to the community hospital, it’s only the community physicians, at the time. When I first started, the night shift had the ER physician. That was the only physician in the building at that point in time. It was a big difference with staff and the resources available.

00:02:36
Fleming:
You said you really liked the community feel. You didn’t really want to be in a teaching hospital. So it was really the fact that with less students around you could really just get into the community?

00:02:48
Virga:
It was more of working with the staff, the associates, and colleagues, and actually living in the same community of the people you were working with. When you worked at Fairfax, most of the people lived up north. [03:00] Very few, if any, lived actually down in Stafford or farther south. You always felt separated from everyone. There wasn’t that socialization outside of work.

00:03:14
Fleming:
So what is a typical day like for you? It’s very different from social workers, but what are some, just experiences you’ve had as a typical day?

00:03:24
Virga:
A typical day like today, our census is extremely high and lots of patients in the emergency room. I look at the flow of the whole department on every unit. The need right now is in the emergency room. My typical day can be starting off in one unit and just going from unit to unit to support and help the other staff. I put myself into the emergency room and try to help do the reviews and look at the patients. My role is to really look at the medical necessity of when a patient comes in to the hospital. What’s being documented? What are we doing to take care of them? What is the plan of care and what do we expect as far as this day when the patient comes in to the hospital?

00:04:09
Fleming:
Wow. Do you go to different units all the time? You don’t have a set unit?

00:04:16
Virga:
No. I’m managing the department, the nurses in the department. I’m actually their manager. I do a lot of chart reviews, audits, as well as trying to support the staff on a daily basis.

00:04:33
Fleming:
So what has been a unit that you have really enjoyed working with?

00:04:40
Virga:
Probably the orthopedic unit is what I feel more comfortable with. The surgeries are where most of my experience has been.

00:04:50
Fleming:
Where did you get that experience with surgeries? Just consistently working?

00:04:56
Virga:
Yes. When I first came to the care management department that’s where I was assigned to work.

00:05:01
Fleming:
When did you come to the care management department, just 1984 or—

00:05:04
Virga:
No. 1996.

00:05:07
Fleming:
1996, okay. So you work more often with the nurses than you do with the social workers?

00:05:14
Virga:
Yes.

00:05:15
Fleming:
Within the care department?

00:05:17
Virga:
Yes.

00:05:18
Fleming:
So what differences do you see in working with social workers versus working with the nurses?

00:05:24
Virga:
The background, the educational background is a little bit different. The nurses are really more focused on the clinical and the medical aspect, where the social workers are focused on the social aspect, the community resources, and the family support. We do take two different paths and we have to closely integrate them because one will definitely affect the other. We do have a team on each unit, a social worker and nurse do work together just for the knowledge. The social workers may have to rely on the nurses to actually provide them that medical information.

00:05:58
Fleming:
Can you give me some examples of teamwork that you’ve seen in nurses and social workers? [06:00]

00:06:04
Virga:
There’s a lot of advocacy going on. If the social worker has identified that the patient has a need for rehab and an insurance company may not want to approve it. Then as a team together, with the information from the family and the assessment that the social worker does, the nurse will use that in conjunction with the clinical information to be able to strongly suggest and advocate for the insurance company to authorize and pay for the rehab that the patient may need to go to.

00:06:38
Fleming:
With insurance companies, do you find that you are consistently struggling with them, as a nurse?

00:06:43
Virga:
Yes, very much so. It’s very hard for somebody on a phone to actually decide what a patient that we’re looking at should have or should not have. You really need that strong clinical background to be able to talk to them and to be able to push them in the direction that you want them to go in. You’re not always successful, but there’s always a lot of advocacy going on and trying to support the patient.

00:07:07
Fleming:
Have you ever had to deal with them face to face? Have they come to the hospital to see a patient?

00:07:11
Virga:
No. Everything’s done by fax or phone. Sometimes we’re not even talking to people in the same state.

00:07:17
Fleming:
Wow. That has got to be rather difficult, both for you and for the patient.

00:07:22
Virga:
It’s very frustrating.

00:07:23
Fleming:
How do you deal with the families when you’re trying to deal with the insurance companies?

00:07:28
Virga:
You try to explain it to them. It’s very difficult. They don’t understand why things take so long. It can be very rewarding in one sense, when you actually get the outcome that you want. It’s very frustrating for the families, for the case managers, for the physicians, and the nursing staff because sometimes things can take two and three days. So that satisfaction is not there. I don’t think that the families really realize how much on the back end and behind the scenes we’re actually working to advocate for them to get all the benefits they’re entitled to. I don’t think it’s something that they ever understand.

00:08:05
Fleming:
So you say you don’t really work with the community resources, but have you had to, kind of, pull your weight in that manner?

00:08:15
Virga:
Yes, the nurses do. It’s not a routine thing that they do every day, but they are trained on the community resources and they will help when possible to provide the patient with the information and the resources that they need.

00:08:33
Fleming:
What do you do as a nurse if you see a chart, or seeing a patient’s medical records that they have no insurance? Do you go to the social workers?

00:08:44
Virga:
There is a department within the hospital for financial resources that will actually screen the patient for different types of resources that are available in state funding and they actually do a whole screening. The social worker and the nurse aren’t really involved in seeing what type of insurance they may qualify for. [09:00] With the new government exchange services, that department will also help them choose the right insurance policy for them, or tell them what is available. Resources are few and far between, but there are people who don’t realize that they qualify for some assistance.

00:09:20
Fleming:
I understand the VA system is a little difficult to maneuver as well. Can you tell me about maybe some of your experiences with not just the VA system, but trying to deal with the outside sources when there may be some issues with patients?

00:09:36
Virga:
I think some of the difficulty is some of the patients don’t even know their own insurance. It’s something we don’t think about until we have to use it and everyone makes the assumption that they have insurance and are fully covered, and they’re not. There are always limitations to policies. A policy is really based on what their employer has actually contracted. Someone thinks that because their neighbor has Blue Cross and they got everything paid for, I have Blue Cross and I should get everything paid for. But their policy may be completely different. The VA System is a very complicated system. I don’t think the vets really understand what the benefits coverage is because, depending upon when they served, how long they served, and whether they were injured during their service time, their benefit coverage is completely different than the next person or their friend or their colleague that they were with. I think the community not really understanding insurance also makes it extremely difficult. It’s such a complex system. Even as a case manager we are not aware of what every single policy can offer and cover. I find it’s a case-by-case basis. You kind of find things as you go along. We do make lots of phone calls. We do try to find out what the benefit coverage is. One of the difficulties and dissatisfactions with a patient and their families is when we call the insurance company we have to really trust that the person on the phone is telling us the correct information. Then six months down the line you find out that you weren’t really told everything correctly and the policy really didn’t cover everything that they said it did in the beginning. There can be a lot of misinformation.

00:11:21
Fleming:
How often do you handle this type of misinformation that’s given to you?

00:11:27
Virga:
Sometimes it can be on a daily basis.

00:11:30
Fleming:
What do you do?

00:11:31
Virga:
We really explain to the families that we’re providing them with the information that we were given. There’s really no guarantee. There’s nothing in writing and we don’t have everyone’s contract to be review. We do encourage the families to call themselves and to ask questions. I’ve guided families and provided them with questions to be able to ask when they call their customer service and their policy. [12:00]

00:12:03
Fleming:
So what do you do as a nurse with patients on Medicare or Medicaid? I understand they have something called patient’s rights, if they’re on, I don’t know if it’s Medicaid or Medicare. What do you do, as a nurse, in working with those resources?

00:12:22
Virga:
Each patient has their rights when they’re in the hospital. Each insurance policy will have certain rights that the patients are entitled to. Medicare and your Medicaid, usually that means that the patients themselves are retired or may have a financial need and that’s why they qualified for the Medicaid. In working within the hospital, it’s probably one of the most comprehensive and one of the combinations of insurance policies that really can provide the patient the most. In reality, it’s probably one of the easiest to work with when they have the Medicare or the Medicaid.

00:13:11
Fleming:
What about Obamacare? I hear that’s rather complicated. So how do you work with Obamacare?

00:13:17
Virga:
It is very complicated. I think one of the more disappointing, again, is the consumer not really understanding what they’re purchasing. They’re paying high, out-of-pocket expenses each month to have that policy and then come in to the hospital and find out that they have a per day co-pay or additional expense. I think it’s very shocking to them and it’s very hard to deliver that news if we have to. Insurance Verification, another department, will actually verify all their insurance. I thought I would have seen more of an impact with it. We’re still seeing a lot of patients come in that are still self-pay that are just not applying for it. I don’t think I’ve seen the big change, as far as everyone being insured when they come in to the hospital, when this came into effect.

00:14:04
Fleming:
If they’re not insured, do you help them find their way to an insurance company?

00:14:10
Virga:
More so case management finds them either clinic appointments at the Moss Free Clinic and different resources to help with medication expenses. That is one place where we would direct the patient. We do direct them to advance patient advocacy, which would be able to help them with resources as far as obtaining insurance and what they’re able to qualify for.

00:14:35
Fleming:
What does a financial screening look like? You mentioned it earlier.

00:14:38
Virga:
The financial screening usually goes through what the patients’ income is and what their expenses are. Do they have children? Are they married? Are they single? So kind of encompassing their whole life in what their financial picture would look like.

00:14:51
Fleming:
And based on that you’ll help them decide what is going to be the best way for them to—

00:14:58
Virga:
Right. What they would qualify for with their income and their expenses. [15:00]

00:15:07
Fleming:
Looking a little bit at more of the community programs aspect of it, you guys work with homeless shelters, and I understand you work through the community resources. As a nurse, is it different for you? Are you going out into the community or are you still, kind of, moving through those outside resources?

00:15:34
Virga:
As far as referrals made from the hospital, the nurses in the hospital do not go out into the community. We would give the same resources as a social worker, if we were working with somebody who is homeless, or needed a shelter, or going to a free clinic. We go through the same resources as a social worker would. Micah Ministries has a very strong advocate program within our community that helps us with a lot of resources. It’s really phone calls, phone calls and trying to point the patient in the right direction and giving them the resources. It’s very hard too sometimes, when you give them the resources and they just don’t know what to do with it as far as calling and knowing what to ask. We usually spend a lot of time doing that for them.

00:16:31
Fleming:
Again, you mentioned the homeless, do you often see them in the emergency rooms without insurance?

00:16:43
Virga:
They use the emergency room a lot. It’s very unfortunate in the community. If we have a really harsh winter, they don’t have anywhere to go or some of them just don’t want to go to the cold weather shelters. They’ll come into the emergency room for medical treatment. A lot of them have chronic medical problems and they’ll come into the emergency room seeking treatment. It’s also their shelter and the ability to have a warm place to stay and a meal.

00:17:19
Fleming:
In working with the homeless, what have you found that’s most difficult?

00:17:31
Virga:
Their support system. A lot of them have complicated past histories for various reasons. Either they have no family available or they have isolated everyone from their family. They are really alone. There are some good resources out in the community. I also think the chronic medical as well as mental health problems is just a vicious cycle. They don’t know how to get out of that cycle. [18:00] It’s a very difficult road for somebody once they hit that point of homelessness and it’s very hard to pull out of that. There are so many things that are blocking it. When they need to get a job and work, but they don’t have an address to be able to provide to an employer. They don’t have their identification or they’ve lost their license. They’re kind of those unidentified, unnamed individuals that sometimes just live within a community, but really don’t have a permanent place to live.

0018:38
Fleming:
I understand you guys have trainings and things like that on cultural diversity. Do you have anything on how to work with the homeless?

00:18:49
Virga:
Yes. We’re very connected with Micah Ministries, in the Fredericksburg community, who work with the homeless. They’re a very good resource for us. They do come and have worked with us in providing some information on resources. I think just about every social worker and nurse is aware. We call them all the time and try to get patients who may have been lost in the system or not aware of the system with Micah Ministries. They are followed, they are known, and then hopefully there’s a dialogue between them and us so we can keep track and give the patient the best that they can once they leave the hospital.

00:19:30
Fleming:
Going off a little bit more on cultural diversity, as a nurse what other types of programs do you go through here at the hospital? Like racial, gender—just these different types of programs that you have, in order to become more used to working with patients that are different?

00:19:52
Virga:
We do have a department, a resource person within the hospital for cultural diversity and it’s just ongoing education and learning. The community grows so quickly. You do get used to one culture, your own culture or in the community that you’re living and what the norm is. We always called Fredericksburg as kind of that magnet. You’re not quite sure why people just all of a sudden show up in Fredericksburg and you get these new communities and new cultures that come in. It’s always a constant learning process. Constant. You always have to take a step back and really think about it when you’re dealing with an individual that you do not know. What are my thoughts and my feelings? I have to put them aside and just really look at it just from the patient’s point of view.

00:20:41
Fleming:
Can you tell me about some challenges you’ve had with learning about the patient and putting your own feelings aside, as you said?

00:20:53
Virga:
I think the expectation of treatment. In our community and our society as a whole, death is not discussed. [21:00] People are not supposed to die and I think that’s something that’s very difficult. I have very strong views on the appropriateness of hospice and palliative care. There is an appropriate time. Modern medicine is wonderful and has made many strides and advancements, but is medical treatment appropriate for every single situation? When you’re giving options to families that really don’t understand what the long-term outcomes really are it can be very difficult. It’s very hard not to put your own thoughts and feelings into that. You have to be very clinical and be able to explain, whether you like their choice or not, that is the choice that the family or the patient or both has made.

00:21:53
Fleming:
How often do you work on the hospice or palliative care unit?

00:21:57
Virga:
I used to be up there full time for many years. I’m now more of a resource, but I have not been working up there for the past couple of years. I had my own—I don’t know if this is part of the interview. A year ago my husband was diagnosed with leukemia and had a thirty percent chance of survival. It was very difficult because of the way I felt and what I knew. I also think it helped with the end of life discussions with him, having a living will, and knowing what the outcomes were going to be and what could be. He, thankfully, has done very well and is on the road to recovery. We had a much better outcome than expected, but it really put myself into what my own beliefs were. I had my beliefs and they were still strong, even though it became much more personal.

00:22:55
Fleming:
So going through that experience, it helped you see kind of from the family side?

00:23:02
Virga:
It did. It didn’t change my perspective because you know what somebody goes through when they’re getting chemo for months on end and the damage that the chemo does. There may be a point where the outcome may not be what you want, but you have to be strong enough to accept that that is the way it is going to be. It was very difficult, but I was able to have those open conversations with him very clearly about what he wanted and what he would want if the outcome was not what we had wanted.

00:23:51
Fleming:
Switching over a little, what did you notice when you came here? What was first thing you noticed about how they treated their patients? [24:00] Was it different from Fairfax Hospital or the teaching hospitals up in New York?

00:24:08
Virga:
I can’t say it was any different. I think it was just the volume of staff that you had. It was still a very caring environment and a very close environment. One of the things that was very different from even working in New York or Fairfax, is when you’re living in the community you’re working in you actually know the patients that are being admitted. People realize that the patients are their neighbors or maybe somebody that you see in the grocery store or maybe the deli person that always cuts your meat every week. You don’t get that when you’re working in a bigger hospital. I really felt it’s more of a family feel when you’re working in a community hospital and living in the community. You just feel more closeness. I can’t say that we treated the patients any differently. I think that all hospitals and their staff try to be very caring and very compassionate. It is maybe the focus may be a little bit different or, like I said, the volume of who’s around or the staff that’s around at the time.

00:25:28
Fleming:
When you were studying to become a nurse, did you ever come across a definition of what a healthy human being is?

00:25:41
Virga:
Probably that comes more with maturity than actually when you’re in school. Like any of us, when you’re young and you’re in college, you have these really grandiose ideas of what your career is going to look like and you are going to go in and save the day. With maturity, you kind of understand that a healthy individual is someone who can deal with day-to-day life as it presents itself. There is no planning. What you expect will happen, won’t. What you don’t expect will happen, will. I think it’s the adjustment. It’s being able to adjust on those days where it may not be a great day. It’s being able to be happy in the days that it actually turns out to be a wonderful day. So a healthy individual—yes, you have all spectrums of sickness and wellness, but it encompasses everything from physical to mental to spiritual. Being able to understand yourself and accept who you are. It’s being able to take care of yourself before you take care of anybody else because you don’t do anyone else any good if you don’t take care of yourself.

00:27:00
Fleming:
You see Mary Washington really focusing on what you see as a healthy human being? They want people to know that they can adjust to life and be flexible in situations. Is that where you see Mary Washington kind of?

00:27:17
Virga:
Yes.

00:27:25
Fleming:
What do you think about the kind of medical sociologist, nurses, and really anybody who works in the hospital field, who say that a healthy human being is just medical and not social?

00:27:42
Virga:
I think it’s all encompassing. You can be one of the most medically healthy people who never gets sick, but if you can’t enjoy life because you don’t have the social support or the social pleasures—where you just enjoy each day, whether it’s out taking a walk on a nice day or meeting up with a friend for a cup of coffee—mentally, you’re not going to be healthy and happy. One goes along with the other. There are a lot of very physically sick people. Just genetically, they’re the ones that are always getting sick and always having problems, but they have the best attitudes. They will have a week where they feel awful and they will be happy that one day they feel great. And they try to balance that out. They accept and fight through what they’ve been given, but you need all parts to be able to function and be healthy, totally.

00:28:47
Fleming:
As a nurse, when you are constantly on all these different units and you see what goes on in a hospital, lots of people who have acute or chronic illnesses. Do you find that the patients that have these attitudes are just very inspiring?

00:29:08
Virga:
They really are. Sometimes you wonder where they get the ability to be able to do that. I think it’s very difficult for anyone. You don’t really know what happens behind closed doors, if it’s just the attitude that they put on in front of other people. But I do believe in the long run, they do better. It really makes you stop and think sometimes when you see people like that because sometimes you really don’t understand how they can actually do that. And then you also find the ones that are very grumpy and can be very mean. They’re not nice to the nursing staff. You, in one sense, understand how they can be that way, but you wonder how they can always take it out on somebody else that they don’t even know. [30:00]

00:30:08
Fleming:
Do you ever have a sense or have you ever come across an idea that maybe medicine can create some of these social issues that you see around?

00:30:18
Virga:
I’m not sure I understand the question.

00:30:21
Fleming:
So you mentioned earlier that with all the medical technology and the fact that we’re prolonging life, these new medicines that are coming out. Do you think that, or have you ever seen or just observed that sometimes medicine brings out social issues in the community?

00:30:40
Virga:
Definitely. I think it really does. I think it reinforces the ability for society not to accept the possibility of death. It’s the expectation that people should be cured and should be treated. I shouldn’t even say, “Should be treated.” But, more or less, if a diagnosis is given, well of course there’s a medicine or of course there’s something that you can give me. It’s very difficult when people don’t understand that there is not a cure for everything and sometimes the treatments can be more detrimental than the disease itself.

00:31:25
Fleming:
How have you see social problems be reduced by medicine?

00:31:35
Virga:
I’m sure there are, but I can’t think of anything, now that you asked me that question [laughter]. I mean, we’re always making strides and there are always advancements.

00:31:52
Fleming:
Did you ever come across anything, I know you said school was—you need maturity to kind of really, experience in health care. But did you ever come across anything about equality between classes, races, or gender in working in health care in general, not just at Mary Washington?

00:32:12
Virga:
Not that anything has really stood out because I know when I worked as a nurse on a unit—when I first came to Mary Washington and I was working in the intensive care unit—you’re there to take care of the patient. They’re your responsibility for the time that you’re working. I never, really ever thought about patients that didn’t have insurance or did have insurance or were having financial issues—that was just never, ever brought into the care at all. I still don’t think it is. Case management is a different look because that’s something we have to deal with. When I first came to case management, that’s when I kind of had that moment of, “I’ve never looked to see if the patient had insurance or not.” [33:00] The care was the same. It really didn’t matter what their socioeconomic background was; if they were working, if they were homeless, if they were not homeless, if they had insurance, or they were self-pay. It didn’t matter. Everyone was the same when you took care of them.

00:33:24
Fleming:
What about the idea, or the debate, actually more like, of a right versus a privilege in health care?

00:33:33
Virga:
That’s probably a very strong ethical question and dilemma. [laughter] It’s hard. I think everyone should have the basics of health care available to them. You see the really sad stories of people that really could have been treated, but didn’t come for treatment because they didn’t have insurance and didn’t have the money. By the time they come to the hospital, it can be too late and you really feel for those people. It’s not fair. I think it all comes with an educated decision also, with what’s really appropriate in health care. I think the health care has become such a huge financial burden to the country. It is everybody, no matter what. I’m not talking about the differences in people. I’m just talking straight diagnoses and treatments. When do we come to the point that we stop or enough is enough? I think that’s a very difficult question to answer and probably one that will be debated for years. It doesn’t have to do with who has insurance or who doesn’t have insurance or what the age of the person is. It’s at that point of the diagnosis, what is really the appropriate treatment? Just because modern medicine has it available, does that make it appropriate?

00:35:12
Rigelhaupt:
I’d like to start by going back to 1990. If you could tell me about your first experience with Mary Washington Hospital, maybe it was the job interview? I mean, you were working nearby, so you probably knew something about it? What do you remember about the job interview?

00:35:32
Virga:
The job interview was really kind of funny. Back in the mid-‘80s, there was such a nursing shortage. I actually walked into a building to get an application. I was in shorts and flip-flops and I was hired on the spot. [laughter] Coming to Mary Washington at that time was almost the same way. I had only been living here probably about six months. [36:00] The commute was just absolutely unbelievable. I really didn’t drive much from Stafford and I started driving around Fredericksburg. I knew Mary Washington was here, but didn’t really know much about it. I knew it was a small hospital. I wasn’t really sure as a young nurse, did I really want to leave the teaching aspect and come to a community hospital? I walked into the nursing recruiting office—they actually had that at the time. They had nursing recruiters specific just for nursing. I was in everyday, day-off attire. I did not dress to come in for an interview. I walked in, introduced myself, asked for an application, and got an interview on the spot. Yes, times have really changed. You’re filling out the application, post-interview, and then when can you start? It was very different than what it is today.

00:36:56
Rigelhaupt:
What do you remember about your first shift?

00:37:00
Virga:
I’m not sure I really remember much of anything about my first shift. Gosh, it was so long ago. After orientation, I did go to night shift and I was working the intensive care unit on the night shift. I do remember coming from a teaching hospital where the equipment was much more updated. The testing and different types of treatment available were different in a teaching hospital. That was more of a shock to me. I do remember the old cardiac telemetry monitors. We had to calibrate them with a screwdriver. I actually had to go buy myself a small, little screwdriver to keep in my pocket as part of one of my tools that I had to come to work with.

00:37:44
Rigelhaupt:
What were some of the best parts about the few months that you were working in the ICU?

00:37:50
Virga:
I think with any job, it’s learning something new. It’s a new environment and new people. It’s very exciting. I do remember everyone being extremely friendly, outgoing, and you just kind of get enveloped into that community feel almost immediately.

00:38:12
Rigelhaupt:
Was there any early discussion about core values, or mission? Was that something that maybe came through orientation?

00:38:19
Virga:
There have always been changes over the years. There have been different focuses that Mary Washington has had. I think there has always—they may not have been called the core values, or the ICARE values—but there was something that each year or every couple of years, there was always a goal. That was always our goal: to be there for the community and always show the community that we are here to care for them.

00:38:53
Rigelhaupt:
What were some of the strengths of the nursing program in the ICU?

00:39:00
Virga:
With the nurses, when I first came to Mary Washington there were a lot of changes. They were starting to do more of the cardiac procedures, the cardiac caths were starting to really open that door. I think the strength with the nurses is that the ones in the ICU were really willing to learn. They really wanted to move forward and very open to change. As the hospital grew and wanted to grow their programs, you had the nursing staff willing and wanting to grow with them. I think growth has always been a strength of the nursing staff here at Mary Washington. Everyone is willing to learn, do the best for their patients, and know the most up to date information to be able to provide that excellent care.

00:39:52
Rigelhaupt:
In the early 1990s, cardiac care is an important area of expansion for the organization. What do you remember about what you were learning, where the training was done as nurses in the ICU were learning new treatments for patients?

00:40:08
Virga:
There were a lot of classes. I remember they did have a nurse specialist come in—and I do believe, and it may have been more of a neurosurgery program that I am remembering—and with a few nurses going down to MCV a couple of times and actually having their nurse specialist do training for us. I do remember the new equipment coming in. You would have the vendors with their specialists from the companies coming in and showing us new equipment and how to use it. There was always a lot of training going on and a lot of classes from what I can recall.

00:40:43
Rigelhaupt:
In those, roughly three years, that you were with Mary Washington, but before the new hospital, did you notice a change in level of acuity in the ICU patients? Were more cardiac caths beginning still at Fall Hill and you were treating, providing a higher level of treatment?

00:41:07
Virga:
Not that I can recall. I’d say probably over the past fifteen years, I’ve seen a real huge change. I think it also has to do with the volume of the community. The community is growing: more developments are going up and so a lot more people moving in. Quantico is expanding and the government is expanding. That is where we have kind of seen the acuity: it is with the volume of patients that come in and the aging of the population. That was here when I first started.

00:41:41
Rigelhaupt:
What do you remember about the first time you heard there was going to be this new hospital? Was it already discussed?

00:41:48
Virga:
When I was in orientation, actually, is the first time I recall it. It may have been during my interview, but I remember during orientation they made a big deal. And I want to say, I know the land was cleared. [42:00] I’m not really sure there was much of a building at that point in time, but the land was definitely cleared. At that point, Mary Wash was the furthest south I had ever ventured, so I wasn’t totally sure where it was actually, when I was hired.

00:42:21
Rigelhaupt:
What do you remember about some of the first discussions, not the first, but just the discussions by the administration, things that would be told to the nursing staff about what this hospital would represent as it was being built? I mean, you guys could see that it wasn’t just land cleared. There was a foundation, you were seeing that it was coming. What were you hearing about what it would mean for the organization?

00:42:47
Virga:
I think it was just the expansion, the growth, and the services to provide to the community. I remember a lot of excitement about it. We could expand. We were so limited in the old building. It was the new equipment and having a lot of up to date equipment. New beds. The ability to expand even further, which they did within the first few years, and they expanded the hospital even further. The excitement of, “We’re a community hospital, but look at how much we are growing and what we’re going to be able to provide to the community.” Being that we’re kind of in the middle, it’s a long drive for someone to go all the way down to Richmond or go north into the Fairfax area. Being able to provide those services and having people stay within the community was very important and that was a very important goal that they wanted to convey.

00:43:42
Rigelhaupt:
Was there a sense, even as the hospital was being built and you were hearing about it and knowing that it was coming, was there a discussion that it would turn into a kind of anchor for a regional medical center? Or was it just going to be a newer, better, more modern hospital? This is a medical campus now. Was there a sense as it was being talked about that it would expand to the degree that it has?

00:44:08
Virga:
Not that I recall. I always remembered that we were going to be that community hospital and be able to serve the community. I never thought it would expand as much as it has. Back in the early 90s, you knew they were building the new hospital, but how much could we really do here? I mean the expectations—it has really grown far beyond what I thought it would have.

00:44:39
Rigelhaupt:
What do you remember about some of your, maybe not the final visit, but probably the last visits to the ICU at the new hospital, but there were no patients—

00:44:50
Virga:
Actually I was on staff on the day of the move and I was actually here at the new hospital, accepting patients. I never was in that building after. [45:00] I had worked the day before at the old hospital in preparation, packing up what we needed. I took care of patients that day and then the next day, I showed up here at the new hospital. After the move was done and we had settled everyone in the new ICU, I never walked back into that old building again. I never saw it empty. Now it’s hard to go into that new building [2300 Fall Hill] and you don’t know where you are in relationship to how it’s been remodeled. You really don’t see the old hospital there at all.

00:45:45
Rigelhaupt:
What do you remember about the first shift in the new hospital? What it was like to be treating patients that were decidedly similar, that you were treating two days before, but in this new modern hospital, new equipment and all the things that went along with it?

00:46:00
Virga:
It was very exciting. It was very exciting to me. I think it’s very rare for somebody in their community to actually start in a brand-new building and in a brand-new hospital. Places get remodeled, but this was actually brand-new when it was opening the doors. It was actually a nice feeling because it gave everybody on the staff a sense of renewal. We’re going in a new direction. We have started a new chapter within the history of Mary Washington. It was a lot of excitement. You felt the change.

00:46:39
Rigelhaupt:
Thinking about the first few years after the move into this hospital, what were some of the most important clinical programs that started?

00:46:51
Virga:
Cardiac and neurosurgery were the biggest ones that I can recall and remember. A lot of times I still worked night shift. On night shift you always got second hand information and you weren’t really always involved in the day-to-day activities. It was very hard to do that and I did that for many years. Even though I knew what was going on, I probably wasn’t involved as much. All the educational classes or if new programs came up, certainly everyone was involved in that.

00:47:26
Rigelhaupt:
When the cardiac surgery program came on board, did you notice a change in the patients? Were you treating different patients because there were new clinical programs?

00:47:38
Virga:
I remember the excitement one day—usually we were the hospital that was flying patients out who needed those types of services to another hospital. One day I was working and everyone was all excited that we actually got our first patient flown in. We were being recognized and we had actually gotten to that level: another, smaller hospital was actually flying their patient into us. [48:00] That was a big change. Now again, just kind of opens that next level of care and the next phase of the organization.

00:48:21
Rigelhaupt:
One of the things I’ve learned about the cardiac program is it involves a lot of teamwork. And I got the sense that that was part of an unintended consequence: that the need for teamwork between nurses, physicians, and lots of different staff in that program spread throughout the hospital. Did you notice, thinking in those first few years in the facility, that there was a change in the working relationship between physicians and nurses?

00:48:56
Virga:
Oh yeah. As new physicians came in to the community who may have come from a teaching hospital and wanted to start programs, they really knew how much they needed the support of all the other staff. Really everyone, whether you are a nursing assistant, the housekeeper that cleans the unit and makes sure the rooms are clean, the nursing staff, or the respiratory therapist. We were growing more cohesive as an organization. We were a small community hospital with kind of limited services. You have your community physicians and it was really the old history of the nurse who took the order of the doctor and just kind of followed the orders, took care of the patients, and called the doctor on the phone. The difference is the nurses were becoming more autonomous. We were more educated. There were more nurses going for their master’s degrees and becoming certified. There was definitely more—I think just in a community. If you think of the doctor as the parent, it takes a village. It takes the community to kind of care for that patient, not just the physician. Absolutely, we have grown in many ways with any type of physician service. It takes the entire medical community to be able to care for that patient.

00:50:18
Rigelhaupt:
Was there a certain pushback to that? That’s a change from probably when you started your nursing career in a teaching hospital.

00:50:26
Virga:
There were some difficulties with that. I think some people just get set in their ways and it’s difficult with the change. The physicians that were in the community for a really long time, maybe closer to retirement and now all these changes were happening. I think it was a little difficult for them. I do have some very good memories of those physicians who may no longer be with us and who have retired. [51:00] We really think back of how much has changed. It’s very overwhelming and some stuff you don’t even realize it’s changing as it’s changing.

00:51:14
Rigelhaupt:
What ways do you recall the organization, either in terms of training or even just meetings or advocacy trying to support this cultural change and more team-based of recognizing the multiple levels of staff who are going to need to coordinate in order to treat the kind of patients that are now being treated?

00:51:40
Virga:
There were a lot of growing pains with that. I think with any big business or organization with a big change like that—and I think it took more than just the administration to be able to do that. Everyone had to buy in to be able to work together. It was just a multi-level organizational awareness and it was everyone’s job to make sure that it happened, not just one group encouraging it to happen. Everyone had to be willing to make that change and accept the change and the changes that were coming to be able to work together. In the ultimate end of it, it’s the patient that is our focus. If you really weren’t on board to make that change, then you really weren’t here for the benefit of the patient.

00:52:36
Rigelhaupt:
You mentioned some of the working relationships between physicians, nurses, and administration. I’d also like to include the board there, although maybe you didn’t interact with the board that often. But what was your sense of how well all those different units, which are really important for patient care, worked together as you began here in the 1990s?

00:53:01
Virga:
I’m not sure in the 1990s I really realized there was a board. When you’re working on the nursing unit level, it’s not something that you’re really involved with or actually hear about. Now that I’m in the case management department, we hear about it a little bit more, only because it’s part of the meetings and things that now I have to attend. It’s not part of the everyday thinking when you come to work. I think a lot of the staff is really on the unit level. The nurse managers really get that information from the administration, who may get it from the board or the VPs. You’re not really involved in the inner workings of that or really understand how involved the board really is.

00:53:49
Rigelhaupt:
So thinking about your years here maybe in general, before 1996, what were some of the nursing skills that you had developed that you were most proud of? [54:00] Things that you had gotten good at with experience, that maybe you learned something about in nursing school and that you honed with years of experience?

00:54:12
Virga:
I think in years of experience, one of the things is being able to assess a patient and know that there’s something going wrong. You are able to identify it, speak with a physician, and be able to be part of the treatment before there was an adverse event that occurred. As a nurse you start developing those skills and are able to assess a patient. The patient is making a complaint and you just know something is just not right. I think that’s a very good feeling that you’ve come to that level in your growth as a professional and you’ve really made a difference at that point. You’re just not there following the protocols, following the specific orders, and you do your shift and you go home. It’s that little bit that you pick up on what may not be part of the protocol. Or the family member that you know is just not dealing with something well enough and you’re able to pick up on that and help them. You explain something they don’t understand or just let them vent and talk. I think that that’s very rewarding.

00:55:29
Rigelhaupt:
What are some of the things you remember, a case maybe, you noticed something, an assessment that also might not have been showing up on a monitor and gave advice? I mean that’s part of nursing in the 1990s: there’s a lot of technology, a lot of monitoring and I’m sure to look for some confirmation from a machine. I think what you’re describing is some of the things don’t show up on a machine. What are some of the things you remember about a kind of assessment that there was something that needed attention, but that might not have been showing up through technology?

00:56:12
Virga:
Sometimes it’s just when you’re having a conversation and you’re really listening to what the patient’s telling you and some things may not be adding up. Or the patient will tell you that they’re fine, but their color is off. Or the way their breathing just may not be the way they were breathing an hour ago, but the patient will insist that they’re fine. It’s those types of things that just may not show up in, like you said, machinery or modern training at that point in time. There are lots of instances throughout my career where you’ve kind of walked in and something’s just not right, for various reasons. Sometimes it’s not in a bad sense. Sometimes it’s on the good sense. I remember one young kid and he had some issues. He was in the ICU and of course we have him all hooked up to wires and tubes and he just would not sleep. [57:00] He was hanging out of the bed the whole time. We could not get him to relax and he was extremely confused. His parents were just so upset and I said to the doctor, “I think it’s all the wires and the machinery. It’s just—it’s irritating him. It’s like he’s oversensitive to it.” This was an older doctor that was like “No, no, no. We have to keep him monitored.” I said, “I’ll sit in the room with him.” It was at a time when I guess I was able to. I can’t remember what else was going on. I took everything off, any type of monitoring equipment. I took everything off and sat him up in a chair. He slept for four hours and was a new person when he woke up. His parents could not believe it. I think it was just he just couldn’t comprehend what was going on. He was so confused at the time. All this stuff was touching him, he was rolling and he was getting all caught up. I just took everything off and just sat with him because we had no monitoring equipment. I took it off. The beeping I think was just driving him crazy. I just dimmed the lights and let him sleep for four hours. I remember when his dad came in, his dad just could not believe he was a different person. He thought that they had lost him. So it’s even on a good sense. It’s not necessarily something going wrong, but being able to help that person take that extra step.

00:58:23
Rigelhaupt:
That must have been a very different experience to be in in ICU. No equipment and no monitoring.

00:58:32
Virga:
And then you go, “Did you make the right decision?” The doctor trusted me to be able to do that and then, of course, we ended up putting the stuff back on later. But it was something that you wouldn’t really think of that made a huge difference in that boy’s recovery. Big difference.

00:58:55
Rigelhaupt:
Could you tell me about your decision to leave the ICU and begin working in care management?

00:59:02
Virga:
At the time I had no idea what case management was going to become. It was an opportunity for change and different hours. I worked straight weekends at that point in time. It was a change I really thought was just going to be extremely short term. My kids were young. I wanted to be home during the week. This was, “I can do this for a little while and then I’ll go back.” I haven’t gone back. [laughter] Case management has completely evolved, grown, and you really need your strong nursing background to be able to do this job. You never lose those skills. You’re still interacting with the patients. You’re still interacting with families on certain occasions. I don’t do it as often now, but you still could. It’s just a different aspect of my nursing career.

00:59:57
Rigelhaupt:
Well, thinking about your first—I’m making up arbitrary units of time, few months, years. It really doesn’t matter. [01:00:00] In the early part of your career in case management, what were some of the experiences and knowledge that you had from nursing you brought to it? That you applied to a new work?

01:00:21
Virga:
Being able to put the picture together. Case management is all about investigating the medical record. You have to be able to present a picture to the insurance company, justify why the patient was admitted, why they’re here, and what we’re doing for them. It’s the interpretation of the physician, documentation, the treatments, being able to connect them, and being able to articulate with the insurance company that the patient is here for a particular reason and you are not really getting that information verbally from a physician. You’ve got to draw in from the respiratory therapy notes or the physical therapy notes. You really have to have that medical background to be able to know what a disease process would typically look like, be able to locate that information, and know that it is on the medical record to be able to provide it to the insurance company. Any of the needs that the patient may have after discharge—having the medical knowledge of a disease process and what a patient may require when it’s time to go home is also necessary.

01:01:26
Rigelhaupt:
What were some of the best conversations, or talking about resources early in your career that you had with patients? Conversations that you would have, in some ways, just because you were not charged with bedside care as you had been in the ICU?

01:01:43
Virga:
I think learning about their social history: where they’re from, how many children they have, what their resources were, and you kind of delve more into their personal lives than if you were at the bedside. I think the nurses at the bedside do know about their families that come to visit. Wherein case management we’re really delving down into what happens when they leave the hospital and who is actually going to be there for them. You’re having more of that personal conversation than a medical conversation.

01:02:20
Rigelhaupt:
What were some of the things you learned about the longer continuum of care? Thinking about patient care when they leave? I’m sure it’s something you thought about in the ICU, but you’re also dealing with very sick people in the ICU. Your attention is very much on that patient care right in front of you. What were some of the things you learned about, even something like the disease process or the longer term medical care, as you began working in case management?

00:02:48
Virga:
When you’re working in the ICU, I believe you really have that feeling of, “Well, of course the patient is going to get the rehab.” I don’t think you really thought beyond once they’re out of the ICU and what really happens to that person. [01:03:00] When you’re looking at the longer continuum of care, you really start to realize there are a lot of people in the community who have no support system. They were living alone before they came in and they want to go home alone and they really can’t. What resources are really available to actually assist them in the long term of their care needs? It opens a door to really focus—it’s not something that any of us think about. I don’t think I ever would have thought about it if I was not in this role. I wouldn’t have thought about it with my parents or neighbors, you know? You see them aging. You never see anyone come to visit. They are always alone and these are the types of patients that we start dealing with. When you’re in the ICU, like I said, you’re not thinking about what happens after they discharge from the hospital. It’s just, we’re going to get them out of the ICU, they’re going to go to the floor, and they’re going to continue to be taken care of. It was a whole new way of thinking and really putting that piece together. You really get the sense of that crossover between medicine and community and family and what happens after the hospitalization. They are very protected when they’re here in the hospital. I don’t think families realize, even though they come to visit every single day, they’re really not caring for their family member. The shock of when they go home and they realize how much care they actually need. It’s really piecing together what is the best picture and the care needs of the patient.

01:04:40
Rigelhaupt:
This hospital, like most hospitals in the country, focuses on acute care, treatment while you are here. What are some of the best things that you have seen that the organization tries to provide for a longer continuum of care? Supporting home health or hospice? What are some of the things you’ve seen in the organization trying to support that—it involves care but not necessarily inside the hospital walls?

01:05:11
Virga:
They do have their own home health and hospice company. I think we all try to offer support beyond the walls of the hospital. It’s very complex and it’s very difficult. Patients go home. It’s an invasion of their privacy. A lot of patients refuse to have any type of services or anyone come to their home. I definitely think the organization tries to support it, but that’s a whole other problem, concern, need, that is really beyond the hospital. A patient needs to be responsible for their own care. They need to be responsible for their follow-up and whether they’re going to follow the instructions the physician has given them when they leave the hospital. That’s very difficult because I find, personally, that’s kind of a fine line and really invading somebody’s privacy by saying, “You know we’ve come up with this plan. You’re going to go home and follow all this stuff.” [01:06:00] It’s very difficult. I do think they try with different resources and they’re very open to new resources. It’s whether or not the patient really wants to take advantage of what’s available.

01:06:26
Rigelhaupt:
Soon after or about the time you started in case management, managed care and HMOs had really become more entrenched in the American health care system. Did you notice any distinct changes in the second half of the 1990s in terms of working with insurance companies or the kind of HMO management? Was that pretty entrenched when you started?

01:06:51
Virga:
I think that was pretty entrenched. Probably more in the 2000s I recall seeing the biggest change. It really wasn’t an entitlement that I have a certain benefit so I’m going to get it. The insurance companies have a lot of control on whether or not they approve it. You may have the benefit, but it doesn’t mean you’re going to be given the benefit. I think that’s one of the biggest changes. It appears to be that the hospital is always struggling to justify the care to be able to get the payment for the care that is being provided.

01:07:29
Rigelhaupt:
A large part of the payer mix is Medicare. Is working with Medicare as difficult in terms of getting benefits approved?

01:07:39
Virga:
No. For our role within the hospital, Medicare looks at everything after the patient is discharged. So as far as my role goes? No. Medicare is actually one of the easiest because you kind of know the basics of what the benefits are and you provide them to the patient. It’s after the fact when Medicare kind of goes back over and looks at different types of medical records to decide whether it was appropriate or not. I know about what happens when they do those types of audits, but on my role for the in-patient setting, it doesn’t affect us.

01:08:19
Rigelhaupt:
You mentioned you worked in palliative care and hospice. What are some of the things about working in that unit that might be applicable to other units in the sense of patient care focus or time? I feel like it’s held as distinct and it sounds like there are things that nurses and physicians, case managers and social workers learn in their unit that might be beneficial in other areas of patient care.

01:08:53
Virga:
Definitely. I think it’s across the continuum, no matter where you’re working, there is an appropriate time and a place for the palliative and the hospice type care and discussion. [01:09:00] I think that’s kind of society driven also. The physicians pretty much know their patients on whether or not it can be discussed or will be discussed. Some of them don’t believe in discussing it. It’s not necessarily unit specific as much as the patients on that unit may be more receptive to it.

01:09:37
Rigelhaupt:
Has the work from the case management department with physicians changed over the years you worked with in the department?

01:09:45
Virga:
Yes. In the beginning we were always kind of the bad person, questioning their documentation or questioning their plan for the patient—not really questioning the physicians themselves and their care plan, but more asking questions for clarification to be able to justify the stay. A lot of physicians didn’t understand why. It didn’t matter. Then as far as, “When is the patient ready for discharge?” We’re trying to work through the process. With the physicians, it has really changed to be much more of a collaborative type of relationship because now the physicians realize we can’t be waiting until the day of discharge to start to make plans. It’s become very complex and complicated. They work with us a lot earlier now. We’re more of an advocate. With the case managers being available on each unit, they do seek us out for our information on what’s going on or what have we already developed a plan with the family. It’s much more integrated as far as a working as a team now.

01:10:53
Rigelhaupt:
During your time here there has been an increase in hospitalists. Does that shape your interactions with physicians?

01:11:01
Virga:
Oh yeah. Having them here all the time during the day—yes absolutely. We work very closely and very well with them.

01:11:10
Rigelhaupt:
Do you find the same level of integration discussion with physicians, there’s probably not that many community physicians still?

01:11:19
Virga:
There’s probably a good handful. It kind of depends. I think we have a closer working relationship with the hospitalists because both groups are here all day. The community physicians do know who we are. A lot of them do seek us out and we do collaborate a lot together. But yeah, it’s not as often as you would if it was a hospitalist.

01:11:46
Rigelhaupt:
You mentioned as you began working in case management, that you became more aware of the board, more aware of the administration and their roles. What are some of the things you’ve learned about the ways in which the administration or the board focuses on patient care? [01:12:00]

01:12:06
Virga:
They’re focused on the quality, the community service type aspect, and the customer service. I still think there is a disconnect between the staff on the units and the board. I don’t think that there’s a lot of connection there. I could be wrong. That’s my impression. As you know, they kind of run the hospital. It’s not so much the clinical aspect of it and what goes on, on the unit level.

01:12:48
Rigelhaupt:
Another thing that has happened in your career, is that there is now a smaller hospital in the organization. It’s more like a community hospital, the one that you started in. What are some of the similarities or differences or how would you describe working in terms of providing case management now in a smaller community hospital?

01:13:10
Virga:
I work up at Stafford hospital and our staff goes to both hospitals. The difference I think is more in age. I think the Stafford hospital has a much younger population. There are different needs with that younger population. You see a lot of chronic type issues in a younger population that kind of gets lost when you’re in a population like Mary Washington because it’s an older population. There are some younger people, but they don’t stand out as much. I think you see a lot more socioeconomic problems with younger people. There’s a lot of that when there’s really not a medical problem or a medical need. It’s very hard to find those resources for them. There’s not a lot out there.

01:14:07
Rigelhaupt:
Going back before Stafford existed, what do you remember about first learning that there would be this new hospital and what did you think it would mean for the organization?

01:14:19
Virga:
I really wasn’t sure. I thought it was very close to Mary Washington. I live up there, close to Stafford. Potomac was there. And it was kind of like, “We’re really going to put a small hospital there?” I think it has really grown and the community was very happy to have a hospital that close. It was a nice idea to have something close in that area and it was more of a shock that we were actually putting a hospital up that just seemed very close to Mary Wash. It’s nice having that hospital closer to Stafford. [01:15:00] You don’t realize how far away sometimes Mary Washington can be if there was an issue.

01:15:24
Rigelhaupt:
Did you see a similar level of coordination? I mean did it start in a different way at Stafford? Was case management more involved in the beginning of this is how it’s going to go with patient care, while this organization had practicing long before?

01:15:41
Virga:
No. This case management department wasn’t involved at all when Stafford was opened. It wasn’t until about a year or so later that they realized the department needed to be a part of Stafford.

01:16:02
Rigelhaupt:
What are some of the most important—you mentioned Micah Ministries and the Moss Free Clinic, so I’ll ask more specifically about the Moss Free Clinic. What are some of the ways you’ve seen the organization kind of work with and support the Moss Free Clinic?

01:16:16
Virga:
All the financial support that the clinic gets to be able to stay open. The staff that’s hired there and the volunteer program here at the hospital that really financially supports them. I just think it’s a huge community need that was very important for us to have here on the campus and be able to be financially supported on campus by the organization. That’s huge for the community.

01:16:47
Rigelhaupt:
Is its physical location on the campus important?

01:16:50
Virga:
Yes, I believe so. It’s much easier when a patient is here. The bus service comes through the hospital campus. The staff all knows where it is and you’re not trying to give somebody directions. I think it very important for it to be here on campus.

01:17:18
Rigelhaupt:
One of the things you described earlier was more and more interdisciplinary teams, even some of the social workers and case management do rounds as well as the physicians and nurses. What’s the benefit to the organization with the increase in interdisciplinary teamwork?

01:17:37
Virga:
The interdisciplinary teamwork is a benefit for the organization in the sense that I think it’s better with the patient, better communication with the patient, and more collaboration of care so everyone knows what the next group is doing. It helps with decreasing the length of stay that the patient stays within the hospital and hopefully coordination of post-hospital services are planned for ahead of time. [01:18:00] It would be a benefit for the continuum of care to move more smoothly in a shorter period of time.

01:18:20
Rigelhaupt:
What would you describe as one of the best days you’ve had when you were in the ICU?

01:18:30
Virga:
I think any best day would be when you’re taking care of a patient who comes in very ill. You’re able to move that patient out of the ICU and you know that you’ve made them well. I think any day would be a good day when the patients are actually moving outside the ICU in a more stable condition.

01:18:56
Rigelhaupt:
How would you describe one of the best days or a really good day in case management?

01:19:01
Virga:
When you’re able to provide the patient with services that you worked really hard on. They’re being discharged and you know that you were able to coordinate and provide for them the care that they needed after hospitalization. You’re hoping that it will allow them to remain independent and at home without having to come back and be readmitted.

01:19:29
Rigelhaupt:
What are some of the things you would want the public to know about being an ICU nurse, or an in-patient bedside nurse in general, that might not be common knowledge?

01:19:45
Virga:
You see a lot of things going around now about how nurses aren’t thanked. I don’t think the public really realizes that you can be verbally abused, sometimes during your shift. Nurses come across as a very strong, independent profession. It’s like when you come on for your shift for that day and it’s that deep breath you take and remind yourself, “I’m here to do the best that I can to make sure that my patients are safe and well taken care of.” You do have that sense of, I guess fear, that you want to be able to give the best that you can. I don’t think the public realizes that. It’s not that you just come in and follow the orders that the physician gives you and you go about your day. We are really the eyes and ears, twenty-four hours a day, seven days a week, for the physician. So your nurse is responsible for your care, to identify any type of issues or concerns, and be able to communicate that to the physician quickly and effectively. I don’t think the public really realizes the stress of the job and how much work is actually put into a shift being a nurse. [01:21:00] That goes for a respiratory therapist or a physical therapist or anyone in the medical profession in any sense.

01:21:21
Rigelhaupt:
What are some of the things you want the public to know about working in case management that might not be common knowledge?

01:21:27
Virga:
There’s not a resource for every single problem that a patient has. [laughter] Resources are limited. There are limitations and qualifications and, unfortunately, not everyone qualifies for the services they think they need. Our hands are tied. We are limited. We do not make that choice. We do not say that one person gets something over another. We are bound by the Medicare/Medicaid laws, insurance company benefits, and different regulations. Those are the regulations that we have to follow whether we like them or not.

01:22:11
Rigelhaupt:
You mentioned a number of times resources and to make sure the patient has as much information and access to resources as possible. What are some of the things, the best things that can happen in terms of educating a patient about resources that happen because this is an acute care setting. I’m not sure if my question came through clear. What are some of the ways that case management organization, your colleagues, nurses and social workers, try to use the moment of someone accessing acute care in a hospital and try to use that moment to provide information about these sources and make sure to facilitate access?

01:23:02
Virga:
What ends up happening—I think one of the big disconnects is you provide patients with pamphlets, pieces of paper, flyers with phone numbers on it. They just don’t have the ability or sometimes the support at home or the drive to actually follow through. It’s extremely difficult to be able to spend that time with a patient and make those phone calls for them or pull up your computer in the room and help them fill out the application. That is very difficult, very time consuming, and a lot of times you’re just not able to do that in your role. When you do get that opportunity, it is nice to be able to take that extra step and you know you have gotten them along the way and hopefully they’ll be able to follow through on that. It’s very hard to with a lot of things now being computerized. [01:24:00] There is a lot of population that does not have a computer or know how to turn a computer on and work it. They are very limited. I think it’s very difficult when you’re talking to—not so much the community resources, I think they realize that. The insurance payers say, “It’s on the computer.” Well, I have somebody who doesn’t have a computer. That’s going to be a very big generation gap—now it is, probably for the next fifteen, twenty years until the computer generation actually comes up. They will be in their seventies and eighties with their computers. I think that’s one of the big drawbacks right now.

01:25:04
Rigelhaupt:
I like to end by—and I think I’ve covered a lot of the themes that I had jotted down. One of the ways I like to end is to ask a final question that is actually two questions. One, is there anything I should have asked, that I didn’t? And two is there anything you’d like to add?

01:25:24
Virga:
I have to say, looking back, I’ll just add, looking back on my career and being here at Mary Washington, I really look back at different opportunities. Could I have done certain things? Was this the right place for me? I can really say that I’ve grown up here, professionally as well as personally and the people that I work with are my family. This place. You’re here for twenty-five years and it’s amazing how many people are here for twenty plus years. You have seen them first start their careers: young doctors that were coming here and starting their brand new practice. I think that’s something extremely unique with Mary Washington Healthcare: knowing somebody that you’ve worked with, even the management or the leadership within the organization being here for twenty plus years. I just think that’s extremely unique to our organization. You come to work and you know people. It’s not this turnover all the time and new faces. I am very happy to be here and to have been here for twenty-five years. It’s just as much home as me going home every night.

01:26:51
Rigelhaupt:
That’s a great place to end. Thank you.
[End of interview]

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