Whether it's transportation or post-acute care, rural CMs rise to the challenge

Thinking outside the box is critical for success

Case managers in rural hospitals have to think outside the box and find creative solutions to problems that their big city counterparts rarely face.

Their patients often live a long distance from the hospital and may not have transportation home or anyone to take care of them once they get home. Specialty services are hundreds of miles away.

In many small towns, taxi and bus service isn't available, and even if it were, some patients can't afford it.

"Sometimes just getting somebody home from the hospital is a challenge. We have to use our imaginations and be resourceful to meet the patient's needs," says Ann Jacobsen, RN, case manager at Clinton Regional Hospital in Clinton, OK. The hospital includes 40 beds for acute care patients, four beds in the intensive care unit, and the 10-bed Jim Thorpe Rehabilitation Unit.

When a patient needs transportation home and doesn't have relatives nearby, she gets on the telephone and calls anyone who comes to mind.

"I just go by the seat of my pants and keep calling until somebody says they'll drive the patient home," Jacobsen says.

For instance, there are elderly patients who need to go to Oklahoma City, 87 miles away, for specialty care but don't qualify for an ambulance.

If the patient's only relatives are elderly and don't want to drive on I-40 or face Oklahoma City traffic, Jacobsen contacts neighbors and local churches.

Then there's the dilemma of people who have been injured in an accident on I-40 and totaled their car or damaged it so much it's not drivable. The closest car rental facility is in Oklahoma City.

"Sometimes, people who are in the hospital visiting their relatives overhear me talking on the telephone and offer to take people home. This is a wonderful little town of about 8,000 people, and everybody pitches in to help their neighbor," she says.

"Being a case manager in a rural hospital makes you think a little harder. When situations come up and I don't know what to do, I get on the phone. Sometimes it takes all day or longer to get one patient to Oklahoma City or to line up a discharge destination that the family likes," Jacobsen says.

Transportation is a challenge

Transportation is the biggest challenge for Carol Wallace, BSN, case manager at Mercy Regional Medical Center in Durango, CO, whose hospital serves a population that lives as far as 100 miles away. Albuquerque, NM, is the nearest big city, and it's 200 miles away. Denver is 320 miles away.

"We have to encourage patients to find their own transportation. We don't have the ability to get them home if they live 50 miles away. We encourage them to call on friends and family members to take them home," she says.

Buses from senior citizen centers bring elderly people to Durango from outlying communities for shopping and physician appointments, but they don't come every day and may not be an option for an elderly patient who is being discharged.

Patients who live in Durango and have no other transportation may have to take a taxi home.

If patients are acutely ill and need specialized care, the hospital has a contract with an aviation service to fly them to Denver or Albuquerque.

"We have a lot of patients who are transported to a hospital that can provide a higher level of care right out of the emergency room. We also transport patients to long-term acute care centers [LTACs] via helicopter or fixed-wing plane. Most of these patients are acute and may go to the LTAC for vent weaning," Wallace says.

There is one nursing home in Durango and several others 30 to 50 miles away. The closest rehabilitation facility is 50 miles away.

"We have to rely on family members to provide transportation for our patients, especially if they're going to the rehab facility or to one of the cities," she says.

Funding is sometimes an issue if a patient needs to go to a rehab center or nursing home, Wallace adds.

"If the patient is uninsured, the post-acute facilities won't accept them and we are obligated to keep the patient and provide ongoing care," she says.

Discharge planning

Finding a post-acute or rehab placement for patients who need to be discharged often means transferring the patient to another city, and in many cases, families balk at moving their loved ones that far from home.

For instance, at most of the rural hospitals in the Integris Rural Health, the closest long-term acute care facility is at least two hours away.

"The most challenging part of the job for me is to convince the spouse of an elderly patient that he or she can no longer provide care. Nobody wants to go to a nursing home, but we can't discharge a patient unless it's to a safe environment," adds Gloria Ross, MBA, RN, CPUM, case management director at Bass Baptist Hospital in Enid, OK.

Case managers have to be careful not to give the impression that the hospital is pushing the patient out the door or that their main focus is money, points out Denise Caram, MS, CPUM, CPUR, director of support services for Integris Rural Health, a system of eight rural hospitals with headquarters in Oklahoma City.

"We start talking to the family about discharge on Day 1 and start to educate them about finding a discharge destination where their family member will have the best long-term outcomes. We believe that if you develop the plan of care at the beginning of the stay, the patient and family understand that the quality of the care the patient receives is the most important thing," she says.

The case management staff must find post-acute placement for about a third of the patients admitted to Lake Granbury Medical Center in Granbury, TX, according to Lyn Clark, RN, BSN, director of case management.

"Finding a bed can be a challenge. People move here to be near mom and dad, and they don't want them to be in a nursing home that's an hour's drive, one way," she says.

The area has a large retirement community and just three small community nursing homes, making it necessary to refer patients to skilled nursing facilities in Fort Worth, about 50 miles away.

Bass Baptist Hospital occasionally has paid for patients and families to stay in a motel when the patient has to have radiation every day for six weeks and they live 200 miles away, Ross says.

"We have to use our ingenuity in making sure the patients get the care they need. We work with community agencies and vendors to help indigent patients. If a patient can't pay for his medication and isn't eligible for community programs, we ask physicians to provide samples," she adds.

The hospital has set up an apartment where a patient and his or her family members can live until the family is comfortable providing the care the patient needs after discharge.

"By teaching the families to take care of the patient in a homelike setting, we've been able to send some patients home with ventilators," Ross says.

At Clinton Regional, the average length of stay is 3.5 days, but some patients stay longer if there is no alternative. One recent patient had an eight-day length of stay because she couldn't go home alone and didn't meet the criteria to go to another level of care.

Terminally ill patients often have long lengths of stay when they can't go home but there's no place for them to go.

"The hardest thing for me is when a patient is dying and I know the family. I have to tell them the patient can't stay in the hospital and they don't understand why. They can't take care of the patient at home, and they don't want them to go to a nursing home," she says.

In rural settings, it's extremely important to develop a good relationship with family members, particularly if they live out of town, case managers say.

"We have elderly patients who live on a farm their family has owned for generations but their children have moved away. It's hard to send an elderly patient home if he lives by himself out in the country. I always try to develop a good rapport with family members so I can make sure the patient will get care after discharge," Jacobsen says.

Sometimes, Jacobsen calls her patients at home the night they are discharged to make sure they're OK, especially if home care doesn't start until the next day.

"We encourage patients and families to take a lot of responsibility for care after discharge. We try to bring the family in as much as possible to help with discharge planning. We don't have resources that are easily available. We can't just transport them across the city in an ambulance," Wallace says.