Dedicated CM-SW team care for trauma patients

Coordination begins at ED, ends discharge

When traumatically injured patients are admitted to Dartmouth-Hitchcock Medical Center, the only Level 1 Trauma Center in New Hampshire, their care is coordinated from arrival in the emergency department (ED) through discharge by a social worker and a case manager team dedicated to the Lebanon, NH, hospital's trauma program.

As the social worker for the trauma team, Nancy Trottier, LICSW, MSW, meets the patients and family members in the emergency department whenever possible and follows them throughout their hospital stay.

She works closely with Elizabeth Williams, RN, BSN, CRRN, who manages the care of the patients as soon as they are transferred to the trauma service floor.

"Trauma case management is a very dynamic role. Every patient is different. Two people may have the same injuries but very different support systems and other factors that affect their length of stay and recovery. We work closely together to make sure the patient's and family's needs are met during the hospital stay and that the patient can be safely discharged," Williams says.

Williams, who has a background as a certified rehabilitation registered nurse, focuses on the clinical aspects of care. Trottier concentrates primarily on the patient and family's psychosocial needs and financial challenges.

Both pitch in and do whatever is necessary to make sure that the patient and family members have the support and information they need. "What makes it work is that there is not a sense of 'I do this and you do that'. We see each other throughout the day and constantly work together to make sure that everything the patient needs is being addressed. We've got to be working closely together to quickly assess the patient's needs and do what is best for the patient and family," Trottier says.

Both attend trauma service rounds once a week, updating the team on family support and other psychosocial and financial issues that may be barriers to discharge.

Typical patients referred to the trauma care management team have injuries involving one or all of their extremities, with or without a traumatic brain injury or spinal cord injury. Some patients transfer from the ED to the critical care unit and are later transferred to the floor, while others are admitted directly to one of the specialty surgical units.

Due to the nature of trauma, many of the patients are 18 to 40 years old, with a history of high-risk behavior. About 40% or more are uninsured, a statistic that also is associated with risky behavior.

"Many of our patients are involved with law enforcement and the court system. Substance abuse is a major factor in a lot of the traumatic injuries," Trottier says.

Coordinating their care is challenging because of comorbidities, financial and psychosocial issues that make the discharge planning more complicated, she adds.

"What is important is that these patients and family members get the support they need and have the medical information clearly presented to them from the beginning. We know it takes time for them to really comprehend what has happened, and we make sure they get information quickly about the potential outcomes so they can begin the process of adjustment," Trottier says.

Trauma patients present different challenges from other patients because their hospitalization happened quickly after an unexpected event, Trottier points out.

"These people were not planning to be here at all. They were at work or driving and all of a sudden, they are seriously ill. When things happen so quickly, it's a challenge for the patients as well as their families and friends," she adds.

In addition to whatever psychosocial issues the family had before the accident, a traumatic injury creates more psychological issues as patients and family members deal with the losses created by their accident, Trottier says.

"We work with survivors of an accident in which family members sustained fatal injuries, and we work with people who have lost limbs or been paralyzed by the accident. It's an emotional time, and the families need a lot of support," she adds.

The support often begins in the ED when Trottier meets the family as soon as they arrive.

"I connect with the family as soon as possible and get to know them. It's helpful for them to have a familiar face. The nursing staff changes, the therapy staff changes, but we are there for them throughout their whole hospital stay," Trottier says.

Many of the family members arrive from out of town and are not familiar with the hospital or the community. Trottier helps them learn their way around the hospital and find a place to stay overnight.

She helps the family contact other relatives or friends who can be with them and calls in the hospital chaplain or a priest if the family agrees.

"One of the most important things is to find support for the family member, a relative, or a friend if possible who can add to the support we can offer them," Trotter says

As the patient is transferred to the critical care unit or the floor, Trottier lets the nurse know that family members are here..

"In many cases, the patient was not with the family member when the trauma occurred. They could have just gone to work that morning and the family could be in the emergency room waiting room without knowing what is going on," she says.

At Dartmouth Hitchcock Medical Center, case managers are assigned by physician service.

Trottier and Williams work primarily with patients being treated by the trauma services surgeons, both general surgeons and orthopedic surgeons who treat adults and older teenagers.

They average between 12 and 15 patients at a time, although in summer months, when traumatic injuries are more likely to occur, the census on the unit could be higher.

"A lot of the case management activities involve forward thinking, anticipating the needs of the patient in the future," Williams says.

She begins by looking at what the patient's injuries are, what their post-discharge needs are likely to be, as well as what financial resources and support systems the patient has.

"I try to form a plan in my head before I meet the patient so that when they ask questions, I'll have some answers. It's part of the trust-building process. The patient has suffered a huge loss, and if they are getting information from someone they trust, it helps to understand what is going to happen in the hospital and throughout the continuum of care," Williams says.

Williams' case management activities involve a lot of troubleshooting, determining the patient's needs, finding out what the patient's payer source will or won't cover, and determining what should be happening to facilitate a speedy and safe discharge.

"We may need to get the patient help with medication or get him into a rehabilitation facility. A lot of times, the patients can't be discharged to home because of the physical environment and we have to find a discharge destination," she says.

The needs of trauma service patients vary depending on their home situation, family support, and financial resources. The length of stay hinges on the diagnosis, the extent of the injuries, comorbidities, and other issues, such as drug addiction.

"Some patients are here longer than they should be because they have a lot of other challenges and we have to make sure they have a safe environment after discharge. Some don't have a home. Others are unemployed with no financial resources but need post-acute care, and in some cases, the family isn't willing to help the patient after discharge," Williams says.

Patients 18 or older who sustained a head injury and can't legally make their own decisions have to have a guardian appointed for them.

"These patients have to have someone to act on their behalf. Sometimes, we have to go through the state to get a guardian appointed because they have alienated their families," Trottier says.

The team may help uninsured patients apply for Medicaid or other programs that can help with their care, a process that is complicated when the patient is of legal age but is too severely injured to make his or her own decisions.

"Family members can't sign a document for an adult unless they have guardianship, and severely injured patients may not be able to do so. It's a cumbersome, emotional process that may involve the court system and is complicated," Trottier says.