Leaders describe guideline creation

Staff are more careful now

Case managers at Children's Hospital Boston wrote a successful set of guidelines describing roles and responsibilities in the hospital's collaboration with home care liaisons during the discharge process.

The guidelines have resulted in hospital staff being more conscientious of the work they have to perform at discharge, and they're more careful with follow-up communication and verbalization of expectations, says Erika Penney, RN, MSN, CPNP, CCM, nurse case manager at Children's Hospital Boston.

"We had everyone in our department review the guidelines, and we came to a consensus of whether they seemed valid or reliable," she says. "Everyone agreed that what we'd written were aspects of the hospital's roles and relationships and were important to address."

Here are some of the key components of the guidelines:

Case manager's responsibilities.

"We included the case manager's responsibilities when working with liaisons," Penney says. "Our case management director was very clear that she wanted us to include language explaining that ultimately the whole medical team is responsible for putting together a safe discharge plan, but the case manager has a pivotal role in it."

The guidelines clarify that case managers are responsible for communicating with the multidisciplinary medical team regarding specific discharge planning needs, she adds.

Meetings with patients.

"We always meet with patients and families prior to initiating any referral," Penney says. "We get their informed consent and offer anticipatory guidance regarding any home services they might need."

The guidelines include a line that discusses how the hospital makes referrals based on knowledge of all the different agencies and doesn't have preferred providers, she adds.

"It's our job to talk with the family about what's involved in getting skilled home care services, what they need to know and can expect and what we need to do before liaisons come in," Penney says. "Likewise, the case manager meets with readmitted patients and families to get their agreement on referrals to health care providers they had in the past."

Some insurance companies specify which providers can be used for these community services, so case managers will go over these limitations with patients and their families.

"We make sure to the best of our knowledge that if we know there's one agency that is an in-network provider versus an out-of-network provider, we present that to the families," Penney says.

When case managers lack preferred provider information, they ask the liaisons for more information.

"We will suggest to liaisons that they get back to us after their financial research into whether they can accept an in-network rate," she adds.

Notify liaisons about referrals.

"We notify liaisons when patients are readmitted and families want to use them," Penney says. "We pass along any problems or concerns brought to our attention, and we work with community liaisons to make a plan together about communication and follow-up throughout the process."

Case managers make sure liaisons have all clinical documentation, and they are responsible for facilitating communication between the medical team and patient or family.

It's left to each case manager to decide how to facilitate communication. Some retain more control than others, Penney notes.

"Some will say, 'You must go through me directly rather than the doctor for communication,'" Penney says. "Other case managers are more comfortable delegating to the liaison than others."

Most members of the discharge team view liaisons as part of the multidisciplinary team, she adds.

Case managers also facilitate completion of all necessary documents for the care transition. They make sure the home care provider receives all of the information necessary on the patient's case and funding approvals.

"It's our responsibility to keep liaisons up-to-date on any changes in the patient's status that could impact discharge planning," Penney says. "We keep them informed about anything related to the timing of the discharge or its original plan."

Reporting pending lab results.

This is a shared responsibility, Penney says.

Liaisons are licensed health care professionals who have access to chart records where lab results would be reported, she notes.

"If the home care agency is asked to draw labs, then they need specific information about which labs and whom to call," Penney says. "This is something that could be lost if the case manager is thinking the liaison will take care of it and vice versa."

Case managers are more involved in this follow-up than they might have been previously.

"Typically, case managers were not in charge of discharge specifics other than making sure the transition goes well," Penney says. "The physician in the community would take over and communicate with the home care agency or specialist."

But now it's the case manager's job to make sure the hospital's instructions to home care providers are made clear.

Delegating to liaisons.

"Case managers can request that liaisons ensure communication with all agencies," Penney says. "If more than one agency is involved, they can verify the home care clinicians are scheduled for particular times when they're transitioning from the hospital to the home, and they can verify that equipment will be there."

While some case managers might prefer to handle these transition issues themselves, others could leave it to liaisons, she adds.


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