Improving collaboration with the community

Guidelines spell out responsibilities

Hospitals and home care agencies often collaborate on an ad hoc basis with little attention to standardized policies and procedures. When these collaborations are done poorly, they can lead to problems and readmissions, which is why Children's Hospital Boston decided to create guidelines for case managers working with home care liaisons.

"We had a meeting with a group of home care providers who talked about some problems with referrals they had received — not specifically from Children's Hospital, but in general," says Erika Penney, RN, MSN, CPNP, CCM, a nurse case manager at Children's Hospital Boston.

After the meeting, hospital leaders discussed the feedback and decided to put together guidelines for working with liaisons.

"We wanted to create our own guidelines, making it clear what our roles and responsibilities are when we're working with liaisons," Penney says.

Here is how the hospital created the guidelines:

Seek information and input from liaisons and staff: "We started it informally by talking amongst ourselves and meeting with various liaisons," Penney says. "It took us somewhere between six and nine months to gather all the information, go through several drafts and considerations before we finalized our guidelines."

Everyone in the department was asked to provide feedback. In meetings, staff had conversations centered on issues with liaisons and common themes in what worked and what did not, she adds.

"These conversations led to us starting a formal process of asking for written feedback about the issues the hospital staff had with liaisons and what they wanted to include in guidelines," Penney explains. "We also gathered job documents from other case management colleagues to get a sense of how their job documents were written up."

They also met informally with members of the hospital's liaison team and networked with three other case management departments in the Boston area, she adds.

Focus on communication: "Communication was a big component of where we felt things could fall through," Penney says. "People were not closing the loops and making assumptions the other person had done the work."

Someone might assume the case manager had done this task, and the case manager might assume the liaison had done it.

"We identified several themes that came out of our discussions," Penney says.

They found these characteristics common to a positive collaboration process at discharge:

- Hospital discharge staff and liaisons take time to learn each other's practices and backgrounds.

- They discuss and agree on each other's roles, responsibilities, and expectations in developing discharge plans and following through with the plans.

- They provide time for ongoing communication, including information updates, discussion of needs, and evaluation of progress.

- They recognize that the case manager or the liaison is responsible for various parts of the discharge planning process.1

Outline individual roles: The key is to avoid misunderstandings about the individual roles during the discharge process.

"We created a grid that outlined the roles and responsibilities as described in our discussions," Penney says. "Some are the case manager's responsibility; some are the liaison's responsibility, and some have a shared component."

An example of a case manager's responsibility might be to monitor and evaluate the patient's readiness for discharge. An example of the liaison's responsibility might be to communicate individualized needs and the discharge plan to the agency, and an overlapping responsibility could be to collaborate with the care team regarding what is needed to ensure a coordinated plan.1

"It's the shared component that you have to be most careful about," Penney says. "You need to be careful about communicating this part when you are working together."

Overlapping responsibilities could even include more than one liaison working with a patient.

"We asked liaisons, 'If there are two home care agencies involved in a case, how would you view your responsibility toward talking to the other home care agency?'" she explains.

For example, there might be a home care agency that visits the patient, as well as an infusion agency. Does the infusion company call the home care agency's visiting nurse and explain which pump it's putting in the home and the range of the equipment?

"Some absolutely saw that as their responsibility and would not expect the case manager to do it," she says. "Others said it wasn't their job, and they expected the hospital case manager to take care of it."

That's why the guidelines include instructions for case managers to facilitate communication among liaisons, the medical team, and the patient and family, she adds.

"We realized as an institution we could not predict what our liaisons would or would not do because we were not their employers," Penney says. "The guidelines we wrote were for case managers, informing them of what they needed to think about when they were working with liaisons."

Write job descriptions: Discharge planning managers should write job descriptions for case managers and others involved in the process. They should ask liaisons for their own job descriptions and review these, as well.

They also asked liaisons questions about specific responsibilities, such as obtaining prescriptions for patients, Penney says.

Hospital case managers also have to be aware that their liaison collaborators have different job descriptions and expectations from their employers, so some of the guidelines might not always work perfectly in each liaison situation.

"This emphasizes all the more that we need really good communication in closing the loops, and also need to take time to get to know each other," Penney says. "We need to take time to get to know her practice style, finding out exactly what she is planning to do when she accepts a case."

And the case manager should clearly articulate her expectations for follow-up and provide guidance on how best to work with families, she adds.

Make thorough, but succinct, guidelines: "We have a format at the Children's Hospital that we follow for guidelines," Penney says. "It's all outlined for us, and we have to write it in a specific order."

Following this standard format, the guidelines begin with a description of how hospital case managers work with community home care liaisons when coordinating their discharge plans for patients and families, Penney describes.

"We work with a multidisciplinary team to come to a consensus on what is necessary to get the patient home safely," she says.

"We speak to the liaison's role as vital in communication, and it helps us complete the needs assessment for the family and patient for problem-solving and specific interventions related to completing the discharge plan," she adds. "Effective communication and collaboration is necessary for care transition success."


1. Kelly MM, Penney ED. Collaboration of hospital case managers and home care liaisons when transitioning patients. Prof Case Manag. 2011;16(3):128-136.


• Erika Penney, RN, MSN, CPNP, CCM, Nurse Case Manager, Children's Hospital Boston, Boston, MA. Telephone: (617) 355-2346.