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Hospital, community organization's DP model
CMs help with daily needs & doctor visits
When high-risk HIV/AIDS patients are about to be discharged from Presbyterian Hospital in New York, physicians will call an outside organization called AIDS Service Center of New York for help with the transition in care.
"It's a phenomenal service for people who are at risk of falling out of care," says Sharen Duke, MPH, chief executive officer of AIDS Service Center (ASC).
"We provide the additional support and social connection that makes the difference between a patient getting continued medical care and falling out of medical care," Duke says.
An ASC case manager answers the physician's call to meet with a hospitalized patient. She visits the patient before discharge and asks questions to find out what issues are most important to that patient's care in the community, says Kim Atkins, chief financial officer of ASC.
The case manager will meet with the patient for about an hour, says Cynthia Rossi, MA, senior case manager for ASC.
"We want to see which is the first priority," Atkins says. "Is it substance abuse, mental health problems, or meeting basic needs?"
The case management team's caseload is about 15 to 20 clients, Rossi says.
The key is to find out what that person will need as soon as he or she is discharged from the hospital, and the case manager will figure out how to meet those needs, he says.
"We'll get them in a shelter if housing is a major issue, and we'll make sure they keep their doctor's appointments," Atkins says. "The patient's basic life issues have to be dealt with, and that's what the case management team does."
Before ASC formed the collaboration with the hospital, the hospital's discharge planners would try to meet patients at a first scheduled outpatient visit, but the patients wouldn't show up, Rossi says.
"That's the big reason why the program was implemented, because of the loss of care," Rossi says. "We deal with people who are hard to deal with and who don't want the medical care."
Here's how the discharge planning collaboration works:
1. Case manager meets with patient.
When the physician calls the ASC case manager, she meets with the inpatient social worker and obtains the patient's paperwork, Rossi says.
"They give us the discharge letter of what the patient needs to do in two days," she adds. "Then we go across the street to the outpatient HIV clinic, and the social workers there give us the paperwork we need, saying, 'This is what we discussed, and this is what needs to be done.'"
The hospital physician will speak with the patient about the transition in care program. Then, armed with the HIV clinic's care plan, the ASC case manager will meet with the patient and conduct an intake, Rossi says.
The intakes typically are done two days before the patient is discharged, she says.
Some patients express reluctance to having someone follow them into the community, but Rossi offers them reassurance.
"We've had so many successes with it, people who didn't want it in the beginning, but now they're on the track to better health," Rossi says.
Also, patients sometimes are concerned about confidentiality and privacy issues. They might not want someone to pick them up at their homes, and these obstacles have to be resolved, she notes.
Rossi's main marketing pitch to patients is as follows: "We know you need medical care, but what else do you need? We want to help you with the other things you need so that nothing gets in the way of the kind of medical attention you need."
The key to buy-in is to highlight the kind of help that the HIV/AIDS patients typically need and desire, such as helping them link with a food pantry and finding housing, Rossi says.
"We get all of that done to get them to fully commit to HIV care and medical attention," she explains. "That's what works very well for us."
For high-risk HIV/AIDS patients, the case manager needs to do a lot of hand holding, Rossi says.
"We tell them that after we get everything else stabilized in their lives, then we'll walk them through everything," she explains. "We'll pick them up, stay with them during the clinic appointment and explain medical terms to them."
The case manager sometimes needs to calm down patients when they become impatient or anxious.
"We tell them, 'Relax, you have one more day of this,' and after some calming down, they're very willing to get it over with," Rossi says.
One component of the program's success is the collaboration between the ASC case manager and the hospital social worker, Atkins says.
"At discharge, the social worker and case manager discuss and agree on what is the most important thing the patient will do," Atkins says.
This is more coordinated than other models, where community advisors work with hospital social workers, because both disciplines share the same objectives, he notes.
"We're talking and sharing what our sense of priorities are, and we're working on this together," Atkins adds.
2. Prepare for the patient's discharge.
"We start off and make clinic appointments for the patient," Rossi says. "We do the legwork ourselves, put them on the calendar and bring it with us wherever we go."
The case manager will tell the patient when his or her appointments are scheduled and reassures the patient that the case manager will be there too and make sure they understand what's going on.
Rossi tells patients: "If you have any concerns, you should stop and ask me, ask the doctor; hopefully, it will go as you want it to go."
Based on the initial assessment of the patient's needs, the case manager will begin to look for community resources the patient might need.
If housing is a problem, then the case manager might help the patient complete a housing application.
For HIV/AIDS, the HIV/AIDS Services Administration is a one-stop shop with assistance for housing, food stamps, and other public assistance, Rossi notes.
"Most of the time we pick up the patient from the hospital and take them straight to the HIV/AIDS Services Administration," she says.
If the case managers don't meet patients at the hospital at time of discharge, then it might take a while before they can track them down again, Rossi says.
"That's our biggest hurdle - locating somebody," she says. "We do investigative work when we do intakes and ask them where they hang out."
Case managers also might check local methadone programs and repeatedly visit their homes or hangouts, she adds.
3. Work with patient for long-term disease management.
The patients' HIV medications are distributed at the HIV clinics, which is where the patients go each week to have their viral load checked and to pick up the antiretroviral drugs, Rossi says.
The case managers go with patients on these visits. Once the patient's viral load is undetectable, which indicates the patient has been compliant with his or her medication regimen, then the visits are spaced to once a month. If the patient's medication adherence remains good, then the visits will be spaced to once every three months, Rossi explains.
Another long-term management issue involves comorbidities, including cancer.
"We have a lot of people who have cancer, and that requires more appointments than the HIV treatment does," Rossi says. "They might have to see a radiologist or receive chemotherapy every day."
For instance, one HIV patient who has cancer has chemotherapy five days a week, as well as less frequent HIV clinic visits, she says.
"We provide more support for her, making sure she knows her appointments, making sure she has food, making sure the home health services show up when scheduled, making sure she's comfortable," Rossi explains.
Part of the case manager's job also involves keeping hospital staff informed of patients' cases.
"We call on a bridge line every Wednesday around 3:30 p.m.," Rossi says. "I speak with the psychiatrist, social workers, substance abuse counselors, physicians, and sometimes the treatment adherence team."
For more information, contact:
Kim Atkins, Chief Financial Officer, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875. Email: email@example.com.
Sharen Duke, MPH, Chief Executive Officer, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875.
Cynthia Rossi, MA, Senior Case Manager, AIDS Service Center NYC, 41 E. 11th St., 5th Floor, New York, NY 10003. Telephone: (212) 645-0875. Email: firstname.lastname@example.org.