Pressures escalate to keep patients out of hospital, and ED

CMs play major role in empowering patients to stay healthy

The financial demands on the current healthcare system puts more pressure on case managers to prepare patients for hospital discharge, ensure that they receive care in an appropriate venue, and/or support the patients in managing their chronic illnesses, says Teri Treiger, RN-C, MA, CCM, CCP, a case management consultant based in Holbrook, MA, and past president of the Case Management Society of America (CMSA), with headquarters in Little Rock, AR.

B.K. Kizziar, RN-BC, CCM, CLP, owner of B.K. & Associates, a Southlake, TX, case management consulting firm, adds: "Case managers are going to have to be more involved early on in the treatment process. We've preached this for years, but the impact is even greater today. Case mana gers need to develop a good transition plan, rather than being pressured to move patients through the system."

Treiger adds that case managers should teach people what they need to do to manage their own care and navigate the healthcare system, rather than having them become dependent on case managers to do it for them. "Case managers should empower their patients to become educated and active consumers of healthcare rather than being passive recipients of healthcare," she says.

Kizziar points out that while a few people are purposely non-compliant with their treatment plan, most patients who don't follow the plan don't understand it or don't understand why it's important. For example, some people think they don't need to take medication for chronic conditions if they don't feel sick.

Patients who have repeated admissions or visits to the emergency department often need help understanding their healthcare conditions and treatment options, as well as what they should do to avoid complications and prevent their conditions from getting worse, Treiger says. "People need to understand why they are taking their medication and why it is important for them to continue taking it. It's important for them to understand their treatment regimen, to receive recommended preventative care, and to have a primary care provider they can see for follow-up and general health care," she says.

When patients are hospitalized, case managers need to assess each patient's appropriate level of care, their self-care ability, and what kind of services need to be put into place after discharge, and they need to educate patients on their health condition, medication regimen, and treatment plan. "If the case manager misses the beat on any of these, there's a good chance that the patient will not have a successful discharge and will end up back in the hospital or in the emergency department," Treiger says.

Continuity in care should be a main focus of any treatment plan, she says. Patients need to understand how critical it is for them to have a follow-up appointment after being discharged from the hospital to avoid an emergency department visit or a repeat admission. Case managers should make sure patients have a primary care physician, that they have follow-up care at regular intervals, and that they have a way to get there, she says.

Jodi Cohn, DrPH, research director of geriatric practice innovations for SCAN Health Plan, a Long Beach, CA-based health plan that provides coverage for Medicare and Medicaid beneficiaries, adds that when patients are hospitalized, they are often overwhelmed by their discharge instructions and medication management. It's particularly overwhelming for older people and their caregivers to reconcile their medications and manage complicated medication regimens. "Being in the hospital is not a pleasant experience for anyone, and it is so demoralizing to be rehospitalized. We need to make sure patients have a good transition and are able to avoid a hospital readmission," she says.

Kizziar points out that many patients who leave the hospital don't completely understand their diagnosis and how to care for themselves so they can avoid being readmitted. "In the past, hospital case managers closed the case when patients were discharged. Now they are going to have to reach outside and make sure patients understand their treatment plan and have follow-up care," she says.

It's not enough for the hospital case manager to merely provide the patient and family with a list of resources, Kizziar says. "We have to work with them to help them access the resources and empower them to take control of their own health," she says. For example, case managers can walk patients through a telephone call to their provider and teach them what they need to say to get their message across, she says.

When they develop a treatment plan, case managers should understand the environment that patient is going back to and include that environment in the plan. "Sometimes a patient's living situation may not be conducive to compliance," Kizziar says. If transportation is an issue, the case managers need to help patients find a way to get to their physician office. If the patients are seeking care in the emergency department because they are unfunded or under-funded, the emergency department case managers should help them find primary care clinics that provide care for free or at a reduced cost.

Treiger says: "As the healthcare system moves to patient-centered primary care, case managers at all practice settings will need to work hand-in-hand across the spectrum to help patients manage their care. We need a network of efficient and knowledgeable case managers in different settings who reach out to each other to coordinate transitions of care."

It will benefit the patients if all healthcare providers and payers work together to ensure that transitions are appropriate and that they have educational and follow-up components, Kizziar says.

"The important thing is for case managers throughout the continuum, including payer case managers, to collaborate on care so patients don't get mixed signals about what they are supposed to do after discharge or how to manage their chronic diseases," she says. "If patients get a different message from case managers and other clinicians at each level of care, they either don't do anything about managing their conditions, or they do too much. That's why we have to talk to each other and stop functioning in silos."