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Transition initiated during pre-admit screen
Educate, plan discharge before surgery
At New England Baptist Hospital, in Boston, social workers meet most patients at the pre-admission screening appointment. A case manager follows up with at risk patients after discharge to make sure they have a smooth transition home.
It's all part of the 162-bed orthopedic center for excellence's Legendary Service initiative, launched in 2005 to provider a higher level of service to patients, visitors, and each other. The hospital's average patient population is 90% orthopedic, about 5% medical, and 5% general surgery. The hospital performs almost 5,000 total joint replacements and 1,400 spinal surgeries each year.
The case management department has 7.5 FTE RN case managers and three social workers, all of whom are unit-based. Case managers work 10 hour days, four days a week. All of the case managers who are eligible have achieved case management certification.
"We find that eight hours isn't enough for the case managers to complete everything," says Eileen Galvin, RN, ONC, CCM, director of case management for the medical and surgical facility in the Mission Hill area of Boston. "The longer shifts and four-day workweeks have done a lot for staff retention and satisfaction."
Social workers work five eight-hour days, with one FTE assigned to the preadmission screening unit. They work as a team with the case managers on the unit and are careful to respect each other's role and avoid duplicating services, Galvin says.
Most patients are having scheduled surgery and participate in a multidisciplinary pre-admission screening where they meet all members of the treatment team. During the pre-admission screening, a social worker meets with the patient and family to educate them about case management and how the case management team can help patients during their hospitalization. The team gives patients a brochure describing case management services along with a case manager's phone number they can call if they have questions before surgery.
The social workers assess each patient's home situation, discuss their choices in case they need to go to a post-discharge facility, and educate them about what they can do in advance to prepare for the post-surgical period, such as preparing meals and freezing them. Patients who are having total hip replacement surgery, total knee replacement surgery, or spinal surgery also attend a comprehensive educational class before surgery.
"The goals of both of the pre-surgical visits are better care through education. We want our patients to be better prepared and be informed of their choices," Galvin says. The social workers educate the patients on how to review their insurance benefits and find out what is covered. Some don't have rehab or home care benefits and if they know that before the surgery, they can make better choices about post-acute care, she adds.
After surgery, the treatment team uses a goal-directed pathway developed by the case management team and the clinical team. The pathway clearly defines the goals patients must meet before transitioning to home and is individualized for each patient's needs.
The physical therapy staff writes the projected day of discharge and the goals on a white board in the patient's room and updates it daily, making the family aware of when they need to have everything in place for the patient to go home. At discharge, patients receive an envelope with all of their paperwork, including prescriptions, discharge plan, and post-surgical instructions, along with telephone numbers for the home care agency and the case manager.
Collecting all the paperwork in one place ensures a smooth transition to the next level of care because the home health nurses or the staff at the skilled nursing or rehab facility has everything they need to continue the patient care, Galvin says.
Case managers call all high-risk patients 24 hours after discharge to ensure that they have a smooth transition to home. They use a standard set of questions designed to make sure all that needed equipment has arrived, the home health agency has called, and the patients have filled their prescriptions. They give patients a telephone number to call if there are questions. High risk patients include those going home with intensive services, such as IV antibiotics, those who live alone with a limited support system, or those that the case manager instinctively feels they should check on.
"All patients have a case manager's phone number and can call if they are having problems," Galvin says. "The case manager knows where to transfer the call or they make sure that the patient gets a follow-up call with the appropriate person."
In addition, case managers make four random telephone calls a month to patients, usually two to three weeks after discharge to find out how they are doing, if their discharge needs were met, and if there were any problems. "We go over their treatment plan, their progress, and make sure everything went well," Galvin says. "We discuss any concerns or problems with the appropriate department heads and staff."
The case managers also call patients who were discharged to a post-acute facility after they get home to find out how the post-acute stay went. "We use the information we elicit from the patients who had a post acute stay to make sure we feel comfortable referring patients to certain facilities." Galvin says.
If the patients report problems, the hospital works with the facility to correct them. "We've found that some home health agencies don't have the staff to see the patient as quickly as we expect," Galvin says. "Instead of within 24 hours of discharge, sometimes the visiting nurse may not be able to visit for two to three days. In these cases, we make changes in our referrals."