Laura Richbourg

Transcript

00:00:09
Rigelhaupt:
It is February 20, 2015. We are at Mary Washington Hospital in Fredericksburg, Virginia, doing an oral history interview with Laura Richbourg. The first interviewer you will hear, her voice will come in in a moment, is Abigail Fleming. I will come back in a little bit later with some questions and my name is Jess Rigelhaupt. So Abigail I’ll let you get started.

00:00:32
Fleming:
Hi. So I just have a few general questions I want to start with, mainly about your life as you came to Mary Washington. So when and where were you born?

00:00:42
Richbourg:
I was born in Richmond, Virginia, in July.

00:00:48
Fleming:
So what made you want to be a social worker?

00:00:54
Richbourg:
That’s a little bit of a loaded question. I started out in business and I was a very good student. I grew up in Stafford County and had been one of the top in my high school class. I got to college on my business career, tanked one of my classes, and decided that that may not be the career path I needed to take. I went in and talked with the advisor who kind of laid everything out as far as what was going on in my life and where I kind of wanted to head. Per their recommendation I started taking social work classes and ended up graduating with a social work degree.

00:01:35
Fleming:
What do you mean they, how did they influence you to get into social work?

00:01:40
Richbourg:
Some of it was discussing what types of things I like to do, what my hobbies were, and how I interacted with people. They identified for me that I have a very helping nature and want to see everybody succeed. I’m rather resourceful and so through several different personality-type questionnaires that we went through, they thought that that might be a good career path for me.

00:02:13
Fleming:
When did you start working at Mary Washington Hospital?

00:02:18
Richbourg:
I started here August 1, 1994.

00:02:21
Fleming:
What made you choose Mary Washington? Location or—

00:02:24
Richbourg:
Location had a lot to do with it. I did grow up in Stafford County. I had come back to Fredericksburg after having graduated with my bachelor’s degree. I started out working in an assisted living facility. That was not the career path of my choice. I only lasted there for about three or four months. Then I went to a long-term care facility here in Fredericksburg. Being in the long-term care facility, I worked very closely with the social work staff here at Mary Washington because Mary Washington was the only hospital in town at that point. [03:00] Our patient referral population came from Mary Washington and, actually, the social work staff here at the hospital recruited me when a position came open.

00:03:09
Fleming:
So as a social worker, working in the general community, and as you stated, you worked with geriatrics before. How do you feel as though you’re making a difference in the community, what does that feel like to you?

00:03:22
Richbourg:
Today or?

00:03:24
Fleming:
Just, is there any story that’s kind of like hit you, where you feel like I can tell I’m making a difference in this person’s life?

00:03:32
Richbourg:
As a social worker here at the hospital, I have responsibilities to help people understand what options they have. I spent about seventeen years working on the orthopedic floor, which are patients that break their hips, primarily. When I would walk in, it was usually a relatively mobile person who unfortunately experienced some type of accident and now found themselves to be almost completely immobile. We walk in, as the social worker, to describe what your insurance will cover, what options you have as far as facilities, what your family may have to deal with when you’re at home, and what equipment needs you’re going to have. There were several patients that I dealt with individually, where I could walk in and the spouse thought the only option was to take the patient home. We come in and say, “Well, that certainly is an option, but you also have these options.” We were able to help influence getting a patient to rehab, getting a patient to a facility where they could get daily rehab, multiple times a day, and get much more independent much more quickly than having gone straight home. We help influence the decisions that they make.

00:04:45
Fleming:
So you said you talk to spouses and family members. How does that influence you? How does that influence your work?

00:04:53
Richbourg:
That’s pretty much all we do.

00:04:54
Fleming:
Just pretty much meeting families?

00:04:56
Richbourg:
We’re very patient focused. We want to make sure the patient’s involved, but lots of times we’re dealing with patients who have pain medication on board, have suffered some type of life-altering event, and unfortunately may suffer with dementia. We also have to be able to assess whether they’re the appropriate person to talk to. We deal specifically with the patient and then the hierarchy of who the decision maker would be, post-in-patient.

00:05:25
Fleming:
Just going back, what is a typical day like for you as a social worker here? Forgetting just a specific type of day?

00:05:37
Richbourg:
Working in health care, there really is no particular, typical day. All of us come in and we are on an eight-hour a day shift. We come in about 8 o’clock every morning. We start out in our morning huddle. [06:00] By 8:30 the entire care management department gathers and we go over what’s gone on in the last twenty-four hours, what the nursing census is, how many patients we have in the building, and if there are any plans for anything that needs to happen, such as if we have Joint Commission coming in or if we have any of the regulatory groups that are coming through and surveys are being done. All of that information is being passed on to the staff. Then we deal with patients on a consult basis. You can get a patient in multiple different ways. We all have a nursing census and we have a floor census to show what patients you have on your floor. The physicians can refer patients to us, the nursing staff can refer patients to us, or the patients can ask to see us and then we do some self-referrals. Based on how old the patient is, we have what’s called the LACE score, which talks about the length of stay, the number of admissions the patient has had, the complexity of the patient, and the expected length of stay. You have a high, medium, and low risk associated with whether or not the patient may come back. We also try to see any high-risk patients that come in. Then each individual case manager can make their plans for the day. Whatever you lay out in the morning as to which patients you’re going to see, usually today’s dischargers are the ones we start with, but a crisis could easily happen and something could change. There really is not a typical day and then you hope to get through all the patients before you’re supposed to go home at 4:30. If not, the ones you don’t get to, you see first thing tomorrow morning.

00:07:35
Fleming:
You were talking about and you mentioned something about making sure patients don’t come back in the hospital. I understand that, through my research, that’s a significant thing insurance companies don’t want to happen, they don’t want patients constantly readmitted to the hospital.

00:07:51
Richbourg:
Correct.

00:07:52
Fleming:
So how do you handle that when patients will come in because they don’t see a, like a doctor on a regular basis, and they come in with a serious condition where you know they are going to have to readmitted to the hospital? What would you say?

00:8:07
Richbourg:
We have several different teams in place to try to help with that process. If a patient comes in without any health insurance, we utilize the Moss Free Clinic and there are several other clinics in the area that provide care for an indigent patient. If it’s a patient who has health insurance, we refer them through Health Link and we try to set up an appointment for them before they ever leave the hospital so they can start to receive that follow-up care. Unfortunately, in dealing with people, not everybody makes the best decisions sometimes. There are some patients that we aren’t going to be able to help, but we try to put as many safety nets in to place as we can so that doesn’t happen.

00:08:47
Fleming:
What are some of the other programs you associate with in the community?

00:08:51
Richbourg:
We’re very active with Moss Free Clinic. Dr. [Powell]’s clinic, we’re very active with the Fredericksburg Christian Clinic, The Guadalupe Clinic, which is down in Westmoreland. [09:00] We deal with the area food bank, Micah Ministries, and many programs through the United Way. We deal with the area agency on aging. We deal with adult and child protective services. We deal with all of the navigators, the cancer navigators, the cancer center, and those pieces, depending on the patient population that we’re dealing with. The VA system. We deal with all of the agencies, of course: the nursing homes, the acute rehab hospitals, home health agencies, and all of those pieces as well. We have pages and pages and pages of resources.

00:09:47
Fleming:
But, I mean that’s really good. How often do you deal with all these agencies you do? At least each of them once a week, would you say?

00:09:55
Richbourg:
Unfortunately, that kind of depends on the patient. So there are some patients that come through that may deal with multiple, multiple agencies just within the day’s time frame. As a hospital system, we probably deal with Micah Ministries every single day. Fortunately, we don’t have to have quite as much dealing with adult and child protective services. We may not deal with them, but maybe once or twice a month. It’s just, unfortunately, dependent on the patient population we’re dealing with.

00:10:32
Fleming:
Can you tell me what it would be like for a patient who’s underinsured or uninsured? Let’s just go with underinsured first.

00:10:44
Richbourg:
Underinsured is more difficult because most of the programs that we deal with when we’re trying to get medications or trying to set up services have programs in place for uninsured. The underinsured tend to be an issue. As an organization, Mary Washington Healthcare will provide indigent care. We have helped patients who can’t afford co-pays or can’t afford the things that they need when they’re ready to leave. We do try to set the patients up with some type of resource before they leave the hospital. Many of the pharmaceutical companies now have programs that will help get the medications that they need, which has been very helpful. We have a gamut of different programs that we use and lots of them have discount cards that we hand out and lots of them have coupons based on the particular medication. We try to get all of that set up beforehand and being the organization that we are, Mary Washington Home Health offers a great deal of assistance as well. We partner with financial counselors here at the hospital. Advanced Patient Advocacy is the group that helps patients who are a little underinsured set up with Medicaid, if they qualify. [12:00]

00:12:06
Fleming:
So for an uninsured person it’s a little bit easier?

00:12:12
Richbourg:
Easier, I guess is the easiest word. But yes, the uninsured patient seems to have more options because the underinsured don’t have the resources out there. The pharmaceutical companies are looking to help them. The providers are looking to able to provide charity care.

00:12:32
Fleming:
Moving on with healthcare, I understand that President Bush, cut Medicare in 2004. Do you remember how that affected your care?

00:12:47
Richbourg:
He cut in 2004?

00:12:51
Fleming:
According to my research.

00:12:54
Richbourg:
Do you remember exactly what it was that they indicated that was cut?

00:12:56
Fleming:
He just cut a lot of spending for Medicare, he cut the budget for it, trying to—

00:13:03
Richbourg:
I don’t know that that impacted health care a great deal. What we primarily deal with is Medicare part A, which covers skilled services. For a patient that can go from here to the nursing center, under the Medicare policy and from a discharge planning perspective, that piece didn’t change. Now the reimbursement based on the DRG, of course, did change. But how we cared for the patients didn’t necessarily change.

00:13:30
Fleming:
What about now that we have Obamacare as it’s called? I understand that’s a little bit more difficult for hospitals to kind of handle and you have to handle the discharge papers and the insurance companies. How do you deal with Obamacare now?

00:13:46
Richbourg:
A lot of those patients are some of our underinsured. They do have health insurance but it doesn’t necessarily cover everything that they need. What Mary Washington Healthcare has done is we’ve partnered with a navigator who has tried to help some of our patients tap into some of the insurances. That individual is located up at Moss Free Clinic. We deal with making sure that we have as much lined up for the patient as we can. At the moment, most of the providers are dealing more with observation, rather than in-patient. One of the struggles that we have currently is trying to prove that the care that we’re providing needs to be provided in an in-patient setting. We have patients who will come in and we’ll provide clinical information. They’ll agree that the patient needs to be here, initially, and then in hindsight they’ll look at it and say, “You know that really could have been provided on an out-patient basis.” Instead of reimbursing for an in-patient stay, they want to reimburse for an observation stay and the reimbursement is significantly different.

00:14:51
Fleming:
And that really affects how you care—does that affect how you care for the patient?

00:14:56
Richbourg:
It affects how we plan. [15:00] It does not necessarily affect the care for the specific patient, but it has created a lot of work teams, determining work flow and how we are going to continue to be able to provide care. We’re working with the physicians to make sure that the cardiac catheterization needs to happen here and can’t be set up in an out-patient basis. If the patient comes in and their cardiac work-up is completely negative, the GI work-up takes place on an outpatient basis versus taking place here. It doesn’t necessarily affect the care that the patient receives, but it affects how we plan to continue to provide care.

00:15:47
Fleming:
I understand that there are a lot of different types of health insurance providers, such as HMOs, PPO’s. Do you work with all types?

00:15:57
Richbourg:
We work with all types of health insurance. We have a whole group that deals with their contracts. They’re part of the revenue cycle and the revenue cycle departments deal specifically with what reimbursement we’re going to receive based on what insurance the patient has. From a discharge planning perspective, the type of health insurance they have doesn’t affect the care that they receive. It may affect what services we set up, based on what the patient can and can’t receive and what agencies they can or can’t use, but it doesn’t affect what care we provide to the patient while they’re here.

00:16:36
Fleming:
So we’re going to switch gears just a little bit. Not completely, but you had mentioned a lot of the programs, specifically Moss Free Clinic, what do you and your staff do in working with the clinic?

00:16:53
Richbourg:
We identify the patient population that is in need of their assistance. Really all we are is the referral source. We provide the patient name, demographics, what medications they’re going to be on, and what follow-up is felt that they need. We call up there, they make an appointment for the patient, and then they assume the care of the patient. So we’re really the referral source.

00:17:17
Fleming:
So you don’t work directly in the Moss Free Clinic? Or you just refer people to the clinic?

00:17:24
Richbourg:
Correct.

00:17:26
Fleming:
You talked about, not that you use shelters, but adult and child protection agencies and you work with the homeless shelters?

00:17:38
Richbourg:
Absolutely.

00:17:40
Fleming:
So how do you manage these programs, or do you use specific social workers that work within these programs?

00:17:48
Richbourg:
All of the social work staff works with all of the agencies. We do have one social worker that is specific to the women and children area. She handles the adoptions, child protective service, and domestic violence, for that population. [18:00] But all of the case managers will deal with any of the agencies. Again, unfortunately, we’re probably more of just a referral source in dealing specifically with the agency. We make sure that the patient gets there, that they qualify for the program, but then after the patient leaves, unfortunately, somebody else is in their bed. We’re just dealing with the patients here.

00:18:25
Fleming:
So what types of patients do you see in the emergency room?

00:18:32
Richbourg:
We see all types of patients in the emergency room. [laughs] We deal with a lot of patients who come in, especially with cold weather issues. We’re making referrals to the cold weather shelter and making sure that the patients have the things that they need. Specifically, today we’ve had a VA patient in the emergency room that we’re getting tapped into the VA system. We’re getting him set up with some services through the VA. We deal with a lot of patients who may be considered more social issues: where the care at home has gotten to the point that the caregiver is just completely overwhelmed. So the patient comes into the emergency room and then the family leaves and is missing. We deal with placements from the emergency room for some patients that have probably stayed home a little longer than they should have and don’t really need to be in the hospital, but can’t safely be managed at home either.

00:19:25
Fleming:
Do you often find that you have patients with more social issues than really need to be in the hospital?

00:19:34
Richbourg:
We probably deal with one or two a week that may be more of a little social aspect. I haven’t heard the patient’s name mentioned recently, but we had an elderly patient that the feeling was she got lonely at home. She would dial 911, come in for a little while, and we would send her home. She would be home for a week or two and then she would be lonely again and she would come back in. There’s some of that social piece as well and we try to hook them up with some resources so that they can stay at home and not tap into the emergency services that way.

00:20:21
Fleming:
Switching over again, Fredericksburg is a relatively diverse area. Do you guys ever work with like cultural diversity programs or what does that consist of?

00:20:39
Richbourg:
We actually have a whole department—it’s a very small department—that deals specifically with cultural diversity. For all of our associates, it’s part of our annual learning that we go through. We have what’s called the Blue Phone. [21:00] If you have a patient who comes in who doesn’t speak English or you have some type of language issue with, it’s a phone that has two handsets. We pick a handset up and say, “I need to speak with my patient. He is from whatever country.” You stay on the line and they get somebody on the other phone who is from that country and that phone goes to the patient. Then we talk through the Blue Phone to the patient: us speaking into the phone, it being translated, and then it coming back to us. We do that piece a lot. Here in the area—I guess it’s been about a year ago because it was cold outside—we had the bus accident. Most of the individuals on the bus did not speak English. They spoke Mandarin Chinese. We dealt with the Blue Phone a lot that day, getting medications for those patients, and getting them to the next level of care. We’ll deal with anybody and everybody.

00:22:04
Fleming:
On the note of literacy, when you use this Blue Phone, do the people that you’re talking to understand the medical terms?

00:22:13
Richbourg:
Correct. They’re specifically hired from a medical background. It is specific to the patient’s dialect, wherever the patient’s from, but they also have that medical piece. We have staff members who may be from that area, but unless they have been trained as an interpreter, we cannot utilize them as an interpreter for the medical issues.

00:22:37
Fleming:
Is there a reason that they can’t? Is it harder to understand the terminology from in the hospital?

00:22:43
Richbourg:
I don’t know necessarily the terminology aspect. We want to be sure that they don’t put their own personal opinions into it. We’re very careful not to utilize family members because we don’t want to be discussing an end of life issue and potentially have the family member not agree with whatever decisions the patient may make. We try to use somebody who is not that close to the situation so that specifically what we’re saying is specifically translated and we can get a real feedback.

00:23:14
Fleming:
In terms of whether the patient understands what’s going on. I mean we speak English, so I can understand, but I don’t know what’s happening to my body and having a lot of medical terms thrown at me is a little discombobulating. Will they explain it on the phone to the patient?

00:23:33
Richbourg:
Correct. If the patient doesn’t understand, then they’ll come back and ask us. We try very hard, from a marketing perspective, to do everything at about a second grade level. We do try to put it in very elementary vocabulary for anybody. Some of the times, dealing with the different countries, what we’re talking about and feel is very elementary still could be very difficult for them. [24:00] There have been times where we’ve had to explain and explain and explain until we can finally get it to the point where everybody understands.

00:24:15
Fleming:
So beforehand, when you were talking about social issues, have you noticed anything in the general community that could be construed as a social issue that needs to be addressed by the hospital?

00:24:33
Richbourg:
We have a very large homeless population and of course Micah Ministries is dealing some with that piece. There are several agencies in Fredericksburg that are dealing with the feeding of our homeless population and working with the homeless population. Mary Washington Foundation works with a lot of those groups as well. I think as an organization we’re very community based. We kind of have our fingers in lots of different agencies that are providing services, but our homeless population does seem to be increasing.

00:25:15
Fleming:
I understand that the hospital supports some of these groups. Do you guys have a specific program that is the hospital’s? Like it’s not in Micah or its not, but it’s specifically Mary Washington Healthcare?

00:25:32
Richbourg:
Mary Washington Hospital Foundation does a lot of that type of service, but we do not have a specific program. We have our home health agency that provides indigent care and the hospital provides indigent care, but we don’t have a specific agency that seeks out that type of thing.

00:25:50
Fleming:
So like with flu shots. There’s no program for you to go into the homeless shelters and give flu shots or do you do that through somebody else?

00:26:01
Richbourg:
Correct, I believe we would find somebody else. I don’t believe we go out and actually do that ourselves.

00:26:06
Fleming:
Do you have any HIV and a lot of things that could be transmitted between people? Do you guys have any programs or sessions to educate the community about different transmissions of diseases and stuff like that?

00:26:26
Richbourg:
Health Link does a lot with the community in providing different information. We do have a diabetes awareness piece, we have an anti-coagulation clinic, and we have a wound-care clinic. All of them will go out and do education. For the most part, we partner with the other agencies to make sure that information is out there. There is FAHASS, Fredericksburg HIV and AIDS Association, and we have partnered with them to provide some education, but I don’t know that we specifically would go out to do something like that. [27:00]

00:27:06
Fleming:
In some of my research, I’ve come across a question, a sort of a debate about health care and I’m just wondering, when you studied social work, when you got your master’s degree, did you ever come across the idea of whether health care is a right or a privilege?

00:27:25
Richbourg:
That comes up at the lunch table quite often. [laughs] And of course there are several different thoughts from that perspective. Technology has gotten us to a point today that people are living longer and have more options. My personal opinion is I don’t know that we do a great job of always explaining what those options will entail, more than we did fifty or sixty years ago. Although fifty or sixty years ago, if you came in with X, Y, Z diagnosis, your prognosis was extremely poor. When you come in today, there are all these things we can do to you, but does that increases your life expectancy? Does it increase your quality of life? That is a discussion that health care providers have quite often. I’m not sure that my life expectancy is as important to me as my quality of life.

00:28:32
Fleming:
Would you say that’s part of the definition of what a healthy human being is? Not just medically healthy, but—

00:28:41
Richbourg:
Correct. The whole picture has to be healthy. I don’t know if it’s as important to me to introduce all the chemicals and things that will have me be here six months longer or if feeling good for three months is good enough.

Fleming:
What challenges have you observed regarding administration, social work, physicians, that sort of thing?

00:29:27
Richbourg:
Specific to physicians or just overall?

00:29:29
Fleming:
No. I mean if you’ve seen any challenges in the hospital just regarding any level of the hierarchy?

00:29:36
Richbourg:
Some of the challenges that we face as a group and some of the frustrations that we face are that patients can make bad decisions. We are an organization of helping people and you can only help people so far. Then they have to help themselves. [30:00] So we tend to get consults for you know, “Mrs. Smith must go to a nursing home.” Well, Mrs. Smith doesn’t want to go to a nursing home. These are the resources we can put into place, but I can’t force her to do something she doesn’t want to. We have some of those struggles, where, as a health care provider, we think we know what’s best for the patient, and maybe it is what’s best for the patient, but the patient’s not there yet. The patient that comes in and you know really needs to go to a nursing facility so they can continue their IV antibiotic, but they really don’t want to go to a facility. Then you’re scrambling to do whatever can be afforded at home. That doesn’t always work at home. We had a patient the day before yesterday and the patient went home on Monday, called on Wednesday and had made the decision that he wanted to go home. He was going to do his IV antibiotics at home and by Wednesday realized that he really should have listened to the case manager and gone to the nursing center because he couldn’t manage at home. From the hospital, we were able to facilitate getting him into a nursing home and he did that from home without him coming back into the building. But it was something that was very difficult and took all day long. We could have done it on Monday when all the paperwork had been in one place, all the signatures had been in one place, and it would have been much easier. We struggled from that perspective: making sure that the patient’s outcomes are the best that they can be and providing as much coaching as we can.

00:31:41
Fleming:
Regarding end-of-life care, I understand that it’s a very difficult topic sometimes to discuss with not only the patients, but with the families. Sometimes when the patient doesn’t have the mental capacity to deal with the idea that they’re coming to the end of their life, how do you manage between the patient and the family as to what’s the most comfortable way and how does the patient want to go? With a chronic illness that’s just going to eventually—

00:32:15
Richbourg:
One of the things, especially from a chronic illness perspective, is we’re trying to talk about that much earlier than historically had happened. Hospice is working on a whole initiative at this point, regarding conversation, The Conversation Project. And pretty much, it’s sitting at the dining room table, talking about what you want to have happen if? What do you want us to do if? How do you want us to handle it if? We’re trying to do that as early as we can before a patient reaches a point of having to make a decision. We also have a palliative care team that will go in and do goals of care. [33:00] That team consists of a nurse practitioner and a social worker that go in and kind of have that “what if” conversation with patients. When dealing with the patient, a lot of times, you kind of have to separate the patient and the family. You deal with the patient and identify what exactly they want to have happen and then deal with the family and marry the two together. Lots of times those conversations don’t necessarily all take place together. It’s much easier if they can take place separately and then come together.

00:33:43
Rigelhaupt:
I want to go backward in time a little bit and ask you, and maybe it’s 1994, but it could well be before then.

00:33:51
Richbourg:
Okay.

00:33:52
Rigelhaupt:
What do you remember about your first interaction with Mary Washington Hospital?

00:34:00
Richbourg:
I was working in a nursing home. It’s funny. I probably would have answered this differently years ago. One of the things that I recognize now, being in the role that I’m in, is when I first interacted with Mary Washington we dealt everything by mail. When they were making referrals to the nursing home they physically had to copy the chart, put it in the envelope, and had to send it through the postman. We would eventually get it and look at the referral to determine how we were going to be able to manage the patient and if we were able to accept the patient. Today we do everything by computer. It’s much, much different. When I was in the nursing home, of course, HIPPA had not come into place and so everything was kind of free game; everybody talked to each other. One of the local physicians—I don’t think he was our medical director, but he did see lots of patients in the facility—he would just call, “Hey Laura, I need you to take Mr. Smith. He’s in the hospital, but he’ll be ready to go today. We need to give him the bed on the west wing.” “Okay.” Now those conversations can’t happen. Everything is very protected. You have to go through the family, you have to go through the insurance, and you have to talk to the patient. Before it was just, “Sure, we can do that.” It’s a very different population now than it was.

00:35:36
Rigelhaupt:
You said you were recruited, what do you, I imagine there was still a formal interview—

00:35:42
Richbourg:
Yes.

00:35:44
Rigelhaupt:
What do you remember about learning about the organization that was new in that interview?

00:35:52
Richbourg:
As I mentioned, I grew up in Stafford County. I can remember when I was probably in the fifth or sixth grade and I had fallen and had to go to the hospital. [36:00] The ambulance got to the house and I remember them asking my mother, “Do you want to go to Potomac Hospital or do you want to go to Mary Washington? I’d go to Potomac if I were you.” I had this impression in my head that Mary Washington may not be all that. Once I had started working with the people and being in the community, this is home. When I came for my interview, we were a much smaller department at the time, but I was interviewed by every member of the department. They sat me at this one long table. The director sat across from me and then everybody else sat at the table. All of them could ask questions and it was a much more community feel. The conversations about what we dealt with the patients and how we dealt with the patients is still reality today. Everybody is their own individual, but you’re trying to coach them and make sure their doing the things they need to do. Where in my head, I had perceived that Mary Washington wasn’t as community oriented or as family as we are, during that interview it became very clear that we are a very close-knit group.

00:37:21
Rigelhaupt:
This is still 1994, but I’m guessing you were in this facility and the new hospital had opened?

00:37:30
Richbourg:
Correct.

00:37:33
Rigelhaupt:
But it sounds like that sense of this being a bigger hospital, being able to provide a higher level of care, wasn’t necessarily as dispersed in that first year after it opened since you were learning new things in that interview

00:37:46
Richbourg:
Correct. Correct. Our heart program hadn’t started. It was just starting up. In some respects, today we’re still that little community hospital. You talk to some of the elderly in the community and they still look at us as this tiny little hospital. The awareness of being a trauma center and having our cardiac services program and having all the different programs that we have now, is just kind of things that happened. We’re still Mary Washington.

00:38:20
Rigelhaupt:
What are some of the upsides of still being thought of as local, small, easily accessed, a sense of connection by the community?

00:38:30
Richbourg:
It is definitely that family-driven—they laugh because I can’t walk through the halls without seeing somebody I know. My husband hates to come because I know too many people. But it is still close knit and the gentleman in the next room may be your neighbor. The guy three rooms down could live down the street. We had a meeting, maybe two or three weeks ago, where they brought a former patient in. It was all of the directors sitting around the table. [39:00] They brought a former patient to talk about his experience when he was here at the hospital. One of the things that had been discussed, prior to the patient coming in, was that you never know who your patients’ are going to be. It could be the man who checks you out at the grocery store. It could be a neighbor from down the street. You always have to be sure that you’re providing care for someone that you know or someone you care about. We’re all sitting around the table and they bring in the former patient and his wife and I kind of made eye contact. They introduced him. They said, “Well, let us explain who we are.” We started going around the table, they got to me and I smiled and said, “I’m Laura Richbourg, but I’m also known as Laura Creech,” which is my maiden name. Both of them stood up. They were two of the teachers who had taught me in school. It is that connection that you continue to have. It’s very family oriented, regardless of how big we are.

00:40:08
Rigelhaupt:
Could you describe your first few months? And that period of time is not specific, but just your day to day job as you began. Some of what you did, some of what you learned, some of how you practiced social work?

00:40:25
Richbourg:
The thing I remember most about the first few months I was here is paperwork. I had never seen so much paperwork in my entire life and some of that paperwork we still have to do today, although it’s electronic now and so it’s much more point and click and point and click and point and click. Then you actually had to physically write everything out. It was a lot of learning about the forms that are necessary. A lot of state forms that we have to fill out and making sure patients have what they need. I had been very focused for one skilled facility. I understood coverage for skilled care and Medicare coverage of nursing home placement, but I only knew my one facility. I also had to learn the other facilities in the area so that I could refer to all of them as well. I think skilled nursing facilities now do a lot of discharges home. When I was in the skilled facility, most patients came in for their skilled care, but never really got well enough to go home. We hadn’t done as much with the durable medical equipment, setting up home health services, and that piece that we do today. I had to learn some of those aspects to be able to make sure patients got what they needed when they left the building. That was my learning curve: I had to make sure that the patients who didn’t go to a facility had what they needed to successfully manage at home.

00:41:54
Rigelhaupt:
What did you learn about the core values of the organization, either in the interview or in the first few months that you were working here? [42:00]

00:42:09
Richbourg:
Mary Washington cares for everyone, regardless of why they’re here or their ability to care for themselves. We had indigent care then and we discuss indigent care now and that’s just business. But there were some things that were different. Patients who would stay a little bit longer because they needed that IV antibiotic and instead of a five-day stay, maybe they stayed a fourteen-day stay so that they get the medicine the entire length of stay. Now we work on trying to find some way to get that at home. It’s always been that we’re going to provide for the patient however we can figure out how to provide for the patient and we still do that today.

00:43:02
Rigelhaupt:
What do you see as the strengths of the social work department? I don’t know if that was what it was called when you first started?

00:43:10
Richbourg:
Actually, when we first started it was social work and now, of course, we’re care management. The strength was how close-knit we were and I think that that’s continued to today. We are a group that arrived at work together and everybody has their own role, but if you’re struggling, you just reach out. If we have to move across the floors, we’ll do that, and then we all leave together. It’s a very cohesive and team-oriented teamwork and I think that has continued.

00:43:51
Rigelhaupt:
How is that able to be sustained as the organization grew? I don’t know the number of employees, but I’m sure it parallels the number of patients, but probably roughly double, in terms of perhaps the patient population.

00:44:08
Richbourg:
Right. When I was first hired, we had probably six social workers and of course we covered the whole building. We started out as social workers and then we had a component of nurses doing discharge planning. Then they combined us with the utilization review nurses and they brought some additional nurses in that were doing more of the insurance piece. We grew in numbers to be able to accommodate the number of patients in the building. Throughout the years we’ve kind of tried different models and changed things a little bit. I’m in a unique situation because at one point they decided that the social workers could also do the utilization review. They brought in a group to teach us some of the medical pieces that as a social worker I wouldn’t have known. [45:00] There are three or four of us that were here during that time frame and got more of that medical background: looking at the medical record, looking at the documentation, and making sure that everything that the patient needed we could accommodate. As a social worker coming straight out of school, that’s not something you would know. I’m very fortunate because I was able to look at both sides of things. Then they kind of separated us back out and now we are back to doing more of just the discharge planning piece of things. Throughout the years, we have morphed into this. When I was first hired, we were probably a department of about twelve to fifteen strong. We’re currently forty-six strong. It’s definitely been a transition.

00:45:58
Rigelhaupt:
Has the growth presented challenges?

00:46:01
Richbourg:
It has presented challenges. We are primarily women and the more women you put together, the more they compare each other. We do have some aspects of, “I work harder than you do.” We do struggle to try to maintain and keep that out of our work life as best as we can. I think right now we’re pretty strong as far as what we’re able to do. Sometimes we have to move folks around and put personalities with personalities or take personalities apart sometimes. I think that we have grown in doing that and have got a very strong group at the moment.

00:46:49
Rigelhaupt:
What were some of the things you had learned in your previous experience in social work that were most applicable, that you drew upon as you began working here?

00:46:59
Richbourg:
I was one of the few that could actually talk through the reimbursement in the nursing center: what the day in the nursing center was like and what you were going to experience. One of the big transitions for patients is, of course, Mary Washington Hospital has all private rooms. If you get sick, you come to the hospital, you’re in a room by yourself, you have a bathroom by yourself, the nurses come in when you need them, and hopefully your progression goes to the point that you get well. In a nursing center you will have a roommate. Pretty much, ninety-nine percent of the time there’s going to be a roommate in the room with you. The two of you have to share a bathroom. Sometimes there are four of you sharing one bathroom. I was able to talk to what it looks like at a nursing center and some of my colleagues have never been in that environment to be able to speak to that.

00:47:53
Rigelhaupt:
What was most exciting to work on in the first few months in the first year you were here?

00:47:59
Richbourg:
That was a long time ago. [48:00] One of the things I remember most—it’s not within the first year—was a bus accident on [Interstate] 95 and it was snowing. At the moment I couldn’t tell you how many patients we got, but we got a significant number of patients and they pretty much told the case management/social work department that we can go home. They didn’t need us. As we were preparing to finish our day, head home, and take care of things, we got the panicked phone call: “We don’t know what we’re going to do with these people. They all have prescriptions. We have no way to give them their prescriptions.” We ended up downstairs. They had the command center in what at that point was the auditorium and what is currently the pharmacy. So we got down there, we got the phones out, and we started making phone calls. And I remember calling the CEO and saying “They’ve told Medical Arts that they can close and go home, but I need them to fill prescriptions!” He replied, “Okay.” They were not happy with us, but they called Medical Arts and said, “You guys can’t leave. You got to help them out.” What we did is we got hotel rooms, over on Route 3. We had one woman and she had a ten or twelve-ish year old child and an infant. We were going to provide them transport to the hotel and of course, you have a group of social workers standing around. I said, “We don’t have a car seat. You can’t put them in the security van. We don’t have a car seat.” There was conversation back and forth and we called upstairs to say, “Do we have car seats? Do we have car seats we send patients home with? Do we have any here?” Because of liability we don’t distribute car seats. We thought about it for a little while. We went to my car and got my daughter’s car seat, put it in the security van with the patient and their daughter, security took them over to the hotel, and then they returned my car seat to me the next day. That’s one of the things I remember most from early in my career. We got everybody accommodated: either families came or we got them to a hotel and we did it safely.

00:50:31
Rigelhaupt:
Being resourceful.

00:50:33
Richbourg:
Right. Yes. [laughter]

00:50:34
Rigelhaupt:
Thinking on your feet, dealing with the conditions that are in front of you is clearly part of the day-to-day job.

00:50:41
Richbourg:
Correct.

00:50:44
Rigelhaupt:
Were there things you remember from your education, a textbook case, about how you would deal with a situation like that, that you remember, and how did it compare with the real world? [51:00]

00:51:03
Richbourg:
Not really. Most of the textbook stuff we did was looking at the laws and looking how things changed. You know there was an element of what would happen in real life, but a lot of that you can’t teach. It’s very hard to figure out how the individual’s going to respond and how you’re going to respond and what resources you’re going to have to be able to pull from. I don’t know that I remember anything from even graduate school that would help me say, “Yeah, they kind of told me how to do that.” I think it’s all just learning on your feet.

00:51:48
Rigelhaupt:
You mentioned the care management and utilization review and if my notes are right, that was around 1998?

00:51:55
Richbourg:
Correct.

00:51:57
Rigelhaupt:
And that sounds like a pretty significant reorganization.

00:52:00
Richbourg:
Correct.

00:52:01
Rigelhaupt:
What do you remember about how that was, how you were told that this was coming, what it meant and why it was going to happen?

00:52:09
Richbourg:
We were told about it in a staff meeting. There really wasn’t a whole lot of pomp and circumstance. It was just kind of, “This is the change that’s going to happen and it’s going to happen soon.” There was a lot of emotion around that because it was taking two different departments and merging us together. One leader had left the organization, so everybody had to answer the leader that was within our team. I don’t know if that was well received by the ones who had to come in to our department, but it was just one of those: “This is what CMS is doing. Medicare says we have to be resourceful and this is how we’re going to be as resourceful as we can.” It ended up being a very good mesh. It worked. We still, today, do the utilization review as well as the case management aspect. It was the right move. They sprung it on us and the flexibility is part of what we have to do, so we just dealt with it.

00:53:18
Rigelhaupt:
Part of what you do is confront difficult situations. Are there things that you ended up learning on the job that you were able, you and your coworkers were able to apply to something, like the shift and the reorganization, that you were equipped to deal with what sounds like a pretty significant change?

00:53:41
Richbourg:
Part of being a good case manager is being flexible, being resourceful, being able to think on your feet, and kind of roll with the flow. That’s just what we had to do when the changes have come about. [54:00] You know, one of the things I told them in staff meeting is, “Just because we told you to do it that way yesterday, doesn’t mean it’s the same way we’re going to do it tomorrow.” You have to be able to figure it out as you’re going along.

00:54:21
Rigelhaupt:
Being able to “roll with the flow,” as you said, how does that come up against order sets and an increased emphasis on evidence-based medicine? I know there’s nothing truly regimented in medicine because every patient is individual, but there certainly is more order sets, more evidence-based medicine. So how do those things work together?

00:54:56
Richbourg:
With my group in particular, it’s all about documentation. So, yes, we have the order sets. You know if you break your hip, you’re going to go home with a walker. Certain medications are going to be necessary for certain diagnosis and for my group. From an evidence-based perspective, it all has to be documented. We all have to be able to explain exactly what we did and exactly how we got to the outcome we got to. The order sets are extremely helpful because I think that helps us stay on a time frame and we make sure that we have a plan and that each patient is getting the same thing. So yes, its individualized care, but the order sets help us not miss anything within that individualized care. The order sets have been very helpful for us. We don’t write orders. We respond to the orders. From our perspective, it’s about that documentation and making sure that everything’s lined up when the patient gets ready to go.

00:55:58
Rigelhaupt:
Although you have a lot of nurses in your department, you also work with a lot of bedside nurses on all the different units.

00:56:06
Richbourg:
Correct.

00:56:06
Rigelhaupt:
How would you characterize the working relationship between social workers and people in care management and RNs on the floor?

00:56:16
Richbourg:
It is a huge partnership. One could not do their role without the other. It’s a daily communication and it’s that handoff from one another. A lot of times a social worker can go into the room and see something that may or may not seem exactly right and then the bedside nurse kind of has to pick that up and roll with it. It’s a huge partnership to make sure that the patient flows the way that they need to and to get to the best level of care.

00:56:46
Rigelhaupt:
Same question, but with physicians; how would you characterize the working relationship with physicians?

00:56:52
Richbourg:
Probably the same way. That may not have always been the case. [57:00] I think sometimes the case management staff was asked to challenge the physicians a little bit more, especially as we have kind of gotten to the point of being very evidence-based, having our order sets, and having the patients flow very quickly through. So we do question, “Why can’t you do that at home? Can we set them up to go to a facility? Why do they have to stay here another night? Why can’t we move them along?” I think that this partnership that we currently have has grown into the partnership. At one point I think they thought we asked too many questions, but today I think that they think the questions are beneficial.

00:57:42
Rigelhaupt:
Part of what has happened over the course of your career is that there are more hospitalists in the hospital.

00:57:50
Richbourg:
Correct.

00:57:51
Rigelhaupt:
I can’t find the date of exactly when that happened or the tipping point, but could you talk about the difference between working with community-based physicians, like coming to round in the morning, maybe at the end of the day and have an office practice as well and the hospitalists who are on staff?

00:58:08
Richbourg:
The hospitalist aspect has helped a great deal from the length of stay perspective because so much happens throughout the course of the day. What you might see if you’re around at 6:00 a.m. could easily change by 2:00 in the afternoon. We struggled with the community physicians because they would either round very early in the morning prior to any of us getting here and being able to ask any of those questions; or some would come middle of the day, though not usually; or they’d come after office hours. We have a time frame of dealing with them via fax machine, via phone machine, but not necessarily having that one-on-one, face-to-face conversation. The hospitalists, fortunately, are in the building. Regardless of what happens, you can pick the phone up and they’ll come see you. We do have more of that face to face and can go in and talk to the patient together. We’re a united front when we’re talking about whatever the issues are and it’s a very nice working relationship.

00:59:07
Rigelhaupt:
How would you characterize the level of support you received from the administration, the social work department when you began?

00:59:16
Richbourg:
When I first began in social work/care management, we answered to the nursing administration. We were part of the nursing services. Probably within the last six to eight years, we have moved to revenue cycle. We are no longer part of the nursing aspect. We now answer to the revenue cycle financial administration. When we were part of nursing, there was always that element of being nurses in case management. [01:00:00] It maybe wasn’t necessarily the healthiest fit all the time. If you got into staffing, there was always that element of “Well, they’re nurses. Why can’t they come back out to the bedside? Why can’t they help do some of these things?” Now that we’re part of revenue cycle, we’re kind of separated from all that. They do look at us from the length of stay perspective and they look at us from a reimbursement perspective, but there isn’t that pull necessarily for the true nursing, bedside nurse behaviors.

01:00:37
Rigelhaupt:
Do you end up having to think more about the financial questions because you are part of revenue cycle, or did it really change your practice?

01:00:47
Richbourg:
I do think it changed the way that we look at things only because by being part of revenue cycle we had more education about some of those pieces. We always knew that of course the patient got billed and we always knew that the claim dropped to the insurance company. Now we know what the insurance provider pays and what issues there are associated with a claim that drops. Where we always had a basic understanding of it, now we have a much more true understanding of it. I think that we have grown from that perspective and are able to help our colleagues understand we have to paint the picture. We have to explain to the insurance company why the patient needs to be here and why they can’t be handled at a lower level of care. That falls on us. Whereas before, we knew we had to do it, we didn’t necessarily understand the why.

01:01:43
Rigelhaupt:
Are there things that you talk about with the patient in terms of, you still do bedside care in some respects? You try and learn more to help in dealing with the insurance companies to try and deal with those questions.

01:01:58
Richbourg:
Correct. We’ll explain to the patient that their insurance providers are the ones helping make some of the decisions, especially when we’re advocating for the patient. Sometimes it’s best that the patient or spouse pick up the phone and call also to help explain exactly what the issues are. We’ve been able to use some of that knowledge to help the patient navigate for themselves.

01:02:27
Rigelhaupt:
The questions of finances are difficult within health care, as you alluded to. People are underinsured, very high deductibles that may be very challenging to meet. And I think the question of finances probably are more distant from, say social work training. Is this another instance in which the education, the textbooks, is disconnected from the real world?

01:02:56
Richbourg:
Correct. [01:03:00] Everything that I have gained from how the bill is dropped and how the claim is paid and all of those pieces, has definitely been on the job training. That was not something that we learned in the classroom.

01:03:13
Rigelhaupt:
What would be the benefit of that being part of social work education?

01:03:21
Richbourg:
In a general social work education, I don’t know that there would be a whole lot of benefit because it’s very specialized, especially for the health care realm. Unless it’s a group of folks going into health care, I’m not sure that there would be a whole lot of benefit to it. It is a huge piece of what we do and it’s a huge aspect of the education we have to provide to the patient. If it were a group of social work students who were coming into the health care realm, it would be very beneficial to know the information, especially the underinsured aspect having to pay. We’re dealing with a group of, largely, middle-aged adults who are doing low premiums so that they have health insurance. They’re not having to pay a whole lot out monthly, but then when they have a crisis they can’t afford to be here. Then the decisions that they make are based on how much their income is. It can be very difficult for the patient and we have to help coach them through that.

01:04:23
Rigelhaupt:
Part of it is you’re dealing with lots of issues from finances to resources to medical care and part of what that is, is what goes on in the hospital and there’s a relationship between the medical staff, the board, the administration. Thinking about your first few years—and I don’t really have a specific time, but early in your career—how would you characterize the relationship between the medical staff and the board and the administration?

01:04:52
Richbourg:
I think as an organization we have grown through the years. We are very community based. Most of the board members are folks that you see out in the community and that has maintained over the years. I think that we are providing more and more information to them so that they have a better understanding of what we do on the in-patient side. It’s been a very healthy relationship as we’ve grown, but I think that we have all grown together. It’s been an interesting transition as we’ve moved through and bought in the extra services that we’ve been able to bring in, built the tower that we were able to build, and expanded the number of beds that we have, and increased the size of our emergency room. As we have determined a need for things, I think we’ve been very well supported in making sure we can provide that for the community.

01:06:00
Rigelhaupt:
In a general way, what do you think social work and care management provides for patient care?

01:06:11
Richbourg:
We provide the knowledge and options for patients to transition to a different level of care from the hospital setting and then making sure that they have the resources necessary to successfully transition to the appropriate level of care.

01:06:29
Rigelhaupt:
Part of what that sounds like is you think over a much longer period of time, versus a physician or a surgeon whose focus may be however many hours they may be doing a procedure. What are some of the ways that you’ve tried to work with the medical staff to think about care in a longer period of time and recognizing that patient care doesn’t end at the end of a procedure?

01:06:58
Richbourg:
Care management has the responsibility of a thirty plus day plan of care. We spend a great deal of time coaching the physicians on, “Yes, the patient does need home health care because they may have X, Y, or Z. Yes, we do need to make sure we send the nurse out just to check on them to make sure that things are going smoothly.” A lot of it is one-on-one care. Within care management, we have a physician advisor who works with us and who also provides education to the staff to help them understand why we’re looking at things beyond tomorrow. We are hoping that the patient can be out of the building and successful at home for, hopefully, an extended period of time.

01:07:42
Rigelhaupt:
What are some of the ways that social workers and your colleagues in care management deal with questions of mental health? I mean, you described a woman, calling every couple weeks because she’s lonely. And that’s a very real issue, but EMS is not necessarily the way—

01:08:01
Richbourg:
They’re not the best plan.

01:08:01
Rigelhaupt:
—to address that. What are some of the ways that you think about mental health and you try and make sure that’s part of patient care?

01:08:09
Richbourg:
We actually have our own psychiatric liaisons here in the building. They are very focused over in the emergency room to help with that type of patient. They do also see patients within the hospital and we have Snowden as part of our health system as well. My department, we primarily refer and ask the psychiatric liaisons to make some of those decisions for us. We don’t deal as much with the mental health piece, but we work very closely with them to make sure that the patients have what they need when they’re ready to go. Mental health unfortunately is one of the issues, that as a community, state, and nation, we are dealing with right now. There are not the services that there even used to be when I first started in health care. [01:09:00] We don’t have the facilities, especially long-term care facilities that can deal with the mental health issues. That continues to be an ongoing problem.

01:09:15
Rigelhaupt:
Part of the patient population that you undoubtedly work with, demographically, is geriatric. Are there things that are unique in terms of mental health that you and your colleagues are more attune to with geriatric patients, that again is different than a medical procedure that may not be as specific?

01:09:37
Richbourg:
One of the issues with mental health and the geriatric population is that if the patient has the diagnosis of dementia, they can’t necessarily be helped by the mental health specialist. There is that whole population of elderly who are confused and don’t get to benefit from some of the mental health programs because they are demented. That is a struggle. We do have some facilities. Unfortunately, they are not right in the immediate Fredericksburg area. They are little bit outlying: Richmond and Charlottesville have locked Alzheimer units that then specialize in more of a mental health capacity. Unfortunately, some of that geriatric population doesn’t get to stay right here in town.

01:10:35
Rigelhaupt:
One of the things I read about in terms of social work in health care is a recognition of disparities in health care. Those might be along racial lines. Are there things, and this kind of ties in a little bit with Abigail’s question with cultural awareness, but are there things that your department tries to think about and have the hospital be cognizant of or try and address some of the disparities that are part of health care in the country?

01:11:09
Richbourg:
I think our department is probably pretty well versed in lots and lots of different areas and we do tend to bring things up, probably more so than bedside nursing or some of those pieces. As an organization, Mary Washington does very well with us to make sure that we can provide for some issues as we go forward. We do have the indigent program. We do provide for different things as we go on. We do have a social worker within the department who is very good at finding things that will help people. Locally we had a situation over the past weekend where a state vehicle ran off of the road. [01:12:00] We had individuals here at the hospital that had been in that state-owned vehicle. She was able to pick up the phone and say, “Hey, the state of Virginia needs to pay for….” We were able to find some funding for some of the things that we couldn’t necessarily get through the insurance provider. We bring up things, but I think we’re more resourceful sometimes to try to find ways to fix things amongst ourselves.

01:12:34
Rigelhaupt:
Do questions of gender matter, in terms of social work practice in the hospital? Again this may be a difference between probably part of social work training and thinking in education and in the textbooks. Understanding that access to health care treatment, the difference between men and women is there, but how does it play out in your day to day? Is it something you’re cognizant and trying to work on?

01:13:00
Richbourg:
I don’t know that it plays out a whole lot in the day to day. Women tend to live longer than men. It’s much easier to find a nursing home bed for a woman than it is to find a nursing home bed for a man because there aren’t as many nursing home beds out there for men. We have some of those struggles. The care that a woman needs sometimes, of course, is very different from what the man needs. But from the services that we’re setting up, I don’t know that the gender plays a whole lot of difference.

01:13:39
Rigelhaupt:
What are some of the ways that your department has tried to focus on questions death and dying, bereavement and knowing that you are kind of interacting with patients and families going through that?

01:13:55
Richbourg:
We utilize our palliative care team a whole lot. We do have one particular floor here in the hospital that primarily deals with our hospice, death and dying piece. We tend to have to rotate our staff through that floor because it can be a very, very difficult floor to work on, especially for any significant amount of time. Then we debrief as a group to make sure that whatever situation we’ve been in, as an individual doesn’t affect me and what I’m doing on a day-to-day basis, and we can kind of let that piece go. You get to the point where you’re very close with the patients, especially a patient with a chronic illness in a death and dying situation who may not be ready to stay at home. You see them come back in and you see the progression. There are individuals who you start to have a relationship with. It can be a very difficult situation for us and we try just to step back from that as best we can. But we’re a group of caring folks and sometimes that’s tough. [01:15:00]

01:15:07
Rigelhaupt:
Are there things that you have implemented as a unit? The same way that there’s order sets, in terms of evidence-based practices, have you guys developed a set of best practices, for say working, as you described a floor that is a hospice floor, what are some of the things you’ve tried to do to create a set of best practices?

01:15:34
Richbourg:
Each floor is very unique and probably each case manager would have their own answer to that question. On our orthopedic floor it’s very rhythmic: you know exactly what the patient is going to need on what day. We’re very practiced from that perspective. You know on our cardiac floor: we have all the medications, we have all our coupons, everything’s printed out and you know exactly what the patient’s going to need and when and it’s all tied in a nice, neat bow and ready to go. Each floor probably has their own routine as to what makes them most efficient in what they’re doing. There are a whole lot of answers, probably, to that question.

01:16:15
Rigelhaupt:
Well as you, part of my asking is that as you described that there is palliative care, which there might not have been when you started. That this is part of patient care now, in terms of The Conversation Project you mentioned. My questions is really, has it become more organized? Are you moving in the direction of dealing with say hospice, and it’s probably never getting as close to the rhythmic of the ortho, but trying to point in that direction?

01:16:46
Richbourg:
Yes. I think organizationally everything is trying to be as efficient as possible and partnering with the bedside nursing to make sure that we have some of those in palliative care. For our congestive heart failure we have the navigators. We have folks that come in who are very specific to whatever the situation is at hand. I think that we’re trying to be as efficient as possible in, unfortunately, a very short time frame. Our average length of stay is about 3.4 days. You don’t have a whole lot of time to recognize the problem, educate on the problem, and to be able to discharge the problem. There isn’t a whole lot of opportunity and you have to be very efficient.

01:17:27
Rigelhaupt:
Average stay 3.4 days. Thinking about efficiency, part of what you and your colleagues have to recognize is that some of what a patient is going confront is not necessarily a specific, acute problem. As they’re leaving, the acute issue is at least changing enough that they are leaving. In a very short period of time, you have to listen for where they’re going to face challenges in their care as they leave. [01:18:00] What are some of the listening skills that you’ve developed to learn about what a patient’s going to need in a very short period of time that you might not have had when you started?

01:18:10
Richbourg:
Some of that has to do with personal experience in dealing with the patients in the patient population. Not only do you have to listen, but you have to reflect and make sure that what the patient is saying is what the patient needs. A lot of what we do at times is just reflect back to the patient what they’ve told us to make sure that they’re hearing what they’re saying, as well as trying to move along where we’re headed. You have to make sure that the patient is telling you everything. Many times they’re not and you have to be able to ask some of those probing questions to get them to tell you the things you’re really looking for. Some patients just don’t want to share exactly what it’s like at home. It can be difficult to determine exactly what they might need because they’re not going to tell us that they’re hoarders. They’re not going to tell us they have no running water. They’re not going to tell us they didn’t pay their electric bill. You have to be able to ask some of those probing questions to try and find out exactly what it is we can help them with. Some of them don’t want us to know all the things they need help with.

01:19:21
Rigelhaupt:
What are some of the best ways you’ve learned to ask those questions that you might want to pass on to a social worker early in their career that you didn’t know early in your career?

01:19:33
Richbourg:
Some of it is: if it doesn’t sound exactly right, question it. Don’t take everything at face value. Just because they’re saying it, doesn’t always mean it’s a hundred percent. When it’s okay to ask some of the questions that you may not be comfortable asking. I had a patient years and years and years ago that we were sending home with IV antibiotics and I had asked what I thought was all the questions. They had running water, they had a caregiver, and they were going be able to manage the antibiotic. Everything was great. They didn’t have a refrigerator. I didn’t know they didn’t have a refrigerator and the medication had to be refrigerated. The patient ended up coming right back because they had no place to store their medicines. But I had posed all the questions. I didn’t know they had a cooler and somebody delivered ice to them every day. We couldn’t do that with their antibiotic. Sometimes you just have to ask and it’s okay to say, “Do you have a working refrigerator?” For many patients that would be something that they go, “Yeah.” But for that fifth or sixth patient that you ask the question to, they’re going to answer “No.”

01:20:54
Rigelhaupt:
Are there questions you’ve asked, or your colleagues have asked, that have ended up shaping some of the decisions that a physician might make about treatment? [01:21:00] That some of the things that you do as social workers in terms of listening and asking some of these questions is different than what a physician might do ends up shaping patient care?

01:21:15
Richbourg:
We have at times been able to find information, such as domestic violence situations or drug history sometimes. It could be behavioral type situations that we’ve been able to share that indeed probably have made a different outcome for the patient. It does have to do with how you pose the question and what questions you’ll ask. Sometimes we have more time to sit and talk to the patient than the physician does. So yes, we definitely have been able to probably mold some of the decisions made by the time we’ve spent with the patients.

01:21:57
Rigelhaupt:
You mentioned domestic violence. That’s one of the things I was going to ask about in terms of how that’s dealt with. If my notes are correct, the Joint Commission has a policy on hospitals recognizing and trying to recognize domestic violence and often they fall under social work. What are some of the programs that this hospital has created and is part of its practice?

01:22:20
Richbourg:
One of the ones that we’re very proud of is we do have— I’m not going to be able to come up with the exact name. I want to say Safe Nurse, but that doesn’t sound exactly right as I’m saying it out loud. We do have a nurse in the emergency room that does all of that sexual abuse aspect and lots of the investigation from that perspective and that has been nationally recognized. She has been to several conferences and spoken on behalf of the health care system. We’ve been very fortunate to come up with some of those pieces. We do have a relationship with some of the shelters and provide information about the shelters and transportation too if we need to.

01:23:09
Rigelhaupt:
This was probably not as relevant as when you started, but certainly probably something you would have still heard about. Part of medicine is also dealing with diseases that create fear. That by the time you started, I think AIDS and the transmission was very well recognized but probably a decade earlier, there was a certain amount of fear around it.

01:23:29
Richbourg:
Sure.

01:23:30
Rigelhaupt:
Even in a health care setting.

01:23:31
Richbourg:
Sure.

01:23:31
Rigelhaupt:
What are some of things that your department, in terms of social work and care management tries to do to address those social fears around a disease or medical problem and not be as much of an acute problem?

01:23:43
Richbourg:
Most recently we dealt with the Ebola and had a whole education aspect, not only for the community perspective, but the associates as well. You just never know when or you don’t know what’s going to come in to the building. [01:24:00] We deal with making sure we have all the appropriate protection and we have the education that we need; we kind of know those pieces and it’s a partnership. Nursing is involved, associate wellness is involved, the physician staff is involved and what we have tried to do is make sure we’re as educated as we can be, so that when the community comes in and has concerns, we can help eliminate those.

01:24:31
Rigelhaupt:
Over the course of your career here, Mary Washington has gone from being a community hospital, to being a regional medical center. Multiple hospitals, multiple sites in the health care system. How has that shaped your work in care management? I mean is it simply bigger or has it changed what you do?

01:24:54
Richbourg:
It’s changed the options that we have and are able to provide. It’s definitely bigger. I don’t know that the day-to-day routine has necessarily changed for us. The patient population has definitely changed for us. The patients that we deal with today, we would have shipped out ten years ago. We’re dealing with bigger wounds, we’re dealing with multiple injuries, and we’re dealing with the traumas that we never had to deal with before. The resources that we need to be able to serve some of the patients are changing. One of the challenges that we have is that Mary Washington Healthcare has grown and our organization has grown and, unfortunately, some of the community facilities have not grown as quickly with us. For example, if you come into the hospital and have to have a trach [tracheostomy] and a PEG tube and if you have a brand new trach you can’t receive care in Fredericksburg. We have to send you to Richmond or we have to send you to Charlottesville. The other services have not grown as quickly as Mary Washington has.

01:26:14
Rigelhaupt:
Are there things the organization has tried to do to address those shortages of other services?

01:26:21
Richbourg:
We have monthly transition of care meetings with the agencies in the area. We have done in-servicing. We have offered education. We have sent our staff to the facilities to try to help from that perspective. I think that within my career we will see those things happen, but unfortunately they’re not yet there.

01:26:47
Rigelhaupt:
Those monthly meetings, sending staff to these facilities—I’m guessing here and I’m presuming that there’s not reimbursement for those.

01:26:59
Richbourg:
Nope. All of that is done at Mary Washington’s expense. [01:27:00]

01:27:03
Rigelhaupt:
How are those decisions made?

01:27:07
Richbourg:
It’s based on the patients’ need and trying to assure that we have the community resources available to provide the care that’s necessary. In working with the agencies, it is to try to be sure the best care is provided right here in our backyard. We offer those resources to the agencies to try and get them up to that point.

01:27:32
Rigelhaupt:
What are some of the ways in which you’ve seen the higher level of care and, as you described, a higher acuity of patients and the benefits of having the surgical sub-specialties and the kind of treatment that the organization has offered within the organization? Are there ways in which they changed working relationships between nurses and physicians, between care management and physicians? Has it changed things other than being able to provide a higher level of care?

01:28:05
Richbourg:
There’s certainly more collaboration between all of those disciplines at this point. Especially with our trauma services: you have a very complex patient and you have to have that collaboration on exactly what we can provide, where we can provide it, what the next step is going to be, and what the obstacles are in getting the patient to the next step. I think there’s been an increase in the communication and collaboration between the disciplines, trying to make sure we do the best for the patients.

01:28:37
Rigelhaupt:
Is that something you would have expected and you would have understood as a health care worker versus, I’ll include myself in this, seeing a trauma surgeon in charge of everything on television? That it does require more teamwork. It does require more specialization. Even going back to the heart program and the cardiac surgery program, that it’s not as much as a surgeon as a lone figure, but the teamwork behind him or her?

01:29:11
Richbourg:
I’m chuckling because one of the nurses made reference to watching a show about firefighters on TV with her firefighter husband, which is like watching a show about the emergency room on the television with her sitting beside him. TV is entertaining, but not necessarily reality. Our trauma surgeon is extremely important in the care of the trauma patient and he saves that individual’s life, but then the other aspects as to how the patient gets to the next level of care is really run by a whole bunch of other people. I don’t know if in any of the things that we do a person could do any of it by themselves.

01:29:57
Rigelhaupt:
Do you remember being involved in planning meetings with trauma? [01:30:00] That your, that care management and social work was a part of the planning, even say years before?

01:30:09
Richbourg:
They came in and talked to us before trauma services started and wanted to know kind of what questions we had, what concerns we had, and where we were headed. They did allow us to be part of the whole work up to opening as a trauma center.

01:30:32
Rigelhaupt:
Do you remember things that you and your colleagues emphasized as being important to have as part of the trauma program that an emergency department nurse or a trauma surgeon wasn’t necessarily as aware of?

01:30:45
Richbourg:
We were very concerned that most of our trauma patients would be uninsured and young. They were going to be the daredevils who were doing things they probably shouldn’t have been doing. How we were going to transition them to another level of care? That continues to be a little bit of a challenge today with traumatic brain injuries or our patients that have other issues. Many times the trauma patients—some of them, of course, do have health insurance—but some of them are those living on the edge, kind of folks, who don’t always have the health insurance or the social aspects that they need in order to successfully manage at home.

01:31:31
Rigelhaupt:
One of the things about medicine in the last thirty years has become higher and higher tech and your job and the job of your coworkers is much more direct in terms of the dynamics in human relationships between patients. How have you seen technology affect patient care?

01:31:55
Richbourg:
As I mentioned earlier, we do everything electronically now. The medical record is electronic, our notes are electronic, and our referrals are electronic. Everything is done through the computer. That’s been a big change for us because we used to have to do everything handwritten and everything was very longhand. We still have the personal relationship with the patient and the family, but in dealing with the agencies, everything’s over the phone or via the computer and that’s been a big, big change. I used to be able to roll off the phone numbers for every nursing home in the area and now we just send a little message by computer and we get a little message back. You don’t have to use some of that stuff that we had to use before.

01:32:45
Rigelhaupt:
Do you have less face to face communication, less voice communication?

01:32:49
Richbourg:
A whole lot less. A lot of it is just electronic.

01:32:55
Rigelhaupt:
Is it harder to stay abreast of what some of the different long-term care facilities are doing in keeping up when you don’t have those conversations? [01:33:00]

01:33:05
Richbourg:
We’ve developed the transition of care meetings and some of those things to try to help bridge that. We invite them to us to let us know what’s going on. From a care management department perspective, we have probably two to three agencies come in every month to give us a, “This is what’s new. This is what’s going on. These are the different things that are happening now.” We try to keep ourselves as up to date as we can by bringing them in. If we’re dealing with a particular patient it might be all electronic, but then we do have them come in for what we call “lunch and learns” to try to help us make sure we’re up to speed on everything that’s out there.

01:33:45
Rigelhaupt:
Throughout our conversation, you have alluded to things like the Moss Free Clinic and other organizations. Part of that is community benefit. What are some of the things that you have observed in care management, with your background in social work that the organization supports towards community benefit that might not be common knowledge?

01:34:15
Richbourg:
I don’t know that I have an answer to that. Of course we do the indigent meds. We do Fred Bus vouchers to make sure patients can get where they need to go. We do the cab vouchers to help patients get where they need to go. We do the medications when patients need medications. I don’t know that there’s a lot out there that folks don’t already know.

01:34:56
Rigelhaupt:
If you go to professional meetings, national meetings, in terms of care management, in terms of social work, do you find that what the organization tries to emphasize in terms of community benefit is on par with your colleagues elsewhere? Is it different? Does it try to do things that you find yourself saying “This is what we do” and they think it’s a great idea. How would you talk about that?

01:35:10
Richbourg:
The last few conferences I’ve been to, Mary Washington has been much further advanced than many of my counterparts. Many of them can’t believe that we help the patients as much as we do. Of course, most of them are for-profit organizations and pretty much the patient just needs to figure it out or they’ll have to come back. We’re trying to help the patient figure it out and prevent them coming back. Most of the times within those conferences, they feel like Mary Washington does more for the patient than many of the organizations do.

01:35:51
Rigelhaupt:
Undoubtedly, being able to provide more requires resources. Have you felt like the administration, in making those decisions, has been still trying to support being ahead of the curve? [01:36:00] I don’t know if that’s the right word but, you know, providing services that some of your colleagues are saying is more than what they do?

01:36:10
Richbourg:
Correct. I think that administration and our board has been very generous with the services that we provide. We, as a department, try very hard to think outside the box. By the time we are asking for services to be provided, we’ve pretty much exhausted anything else that could possibly have even been an option. They’re very generous in what they are allowing us to do.

01:36:55
Rigelhaupt:
Going back to another question, what would you most want the public to know about working as a social worker in a hospital, in a health care setting, and in care management that might not be common knowledge?

01:37:17
Richbourg:
Case managers are unique. From the perspective that we have to be as resourceful as possible and flexible as possible, and while we are limited in what we can do, we accomplish a great deal and we always have the patient’s best interest at heart. The patients don’t always feel that way and not all case managers are created equal. They need to understand that we have always wanted the best for the patient and making sure that whatever they need, they’re going to get and whatever resources they need, they’re going to have. But sometimes that can be very, very difficult.

01:38:07
Rigelhaupt:
What would you most want the public to know about Mary Washington Healthcare that might not be common knowledge?

01:38:19
Richbourg:
Mary Washington Healthcare is still very much a community hospital. We are a trauma center. We do have multiple campuses at this point, but we are still providing the patient care that a community hospital provides and doing the best for the patient.

01:38:39
Rigelhaupt:
My last question is actually two questions, but I’ll try and ask it as one.

01:38:43
Richbourg:
Okay.

01:38:44
Rigelhaupt:
But is there anything that I should’ve asked, that I didn’t, and is there anything you would like to add?

01:38:56
Richbourg:
I don’t think so. [01:39:00] Based on what we had talked about, I think that we went over everything that we intended to. I think that we’re in good shape.

01:39:08
Rigelhaupt:
Okay. Thank you.

01:39:10
Richbourg:
You’re welcome.
[End of Interview]