Executive Summary

Primary care physicians too often are out of the loop when their patients have surgery or are hospitalized. An Arizona case management model seeks to keep them aware of what’s going on and give them an opportunity to improve care during transition and crisis periods.

• Transitional case managers also keep patients’ specialists aware of any surgeries or hospitalizations.

• CMs send HIPAA-compliant text messages and updates.

• Post-discharge, CMs provide follow-up and help patients link with needed community resources.


Linking hospital providers with community physicians is challenging for transitional case management, but one organization has found that having the case managers look out for patients both in and out of the hospital helps keep hospital readmission rates at a low range — 3% to 5% — for a senior population.

Hospital physicians use the texting system to let primary care doctors know when their patients are discharged or seen in the emergency department (ED), says Karen R. Vanaskie, DNP, RN, MSN, care management program director at Scottsdale Health Partners in Scottsdale, AZ.

“Our primary care physician [PCP] network used to never know when patients were in the hospital,” Vanaskie says. “A patient would come in for a visit and say, ‘I fell and broke my hip and spent a month in a nursing home,’ and the primary care provider was never involved.”

The transitional case management program keeps PCPs in the loop, and the program lets patients know about feedback to the community doctors, she adds.

Primary care physicians often have seen their patients for years, so it’s a very important focus to make sure they know the treatment plan devised by the hospital. “Many times a primary care physician has critical medical information about the patient that a hospitalist on a quick visit isn’t going to know,” Vanaskie says.

The transitional case management program also keeps patients’ specialists — including cardiologists — aware of hospital and ED visits, she says.

Transitional case managers (TCM) are both registered nurses and licensed social workers. The organization has four TCMs with one in post-acute and one in each of three hospitals. Their census typically is 12-15 patients per day. The nurses handle patients’ transition needs in the hospital, and the social worker provides follow-up and support in post-acute settings, Vanaskie explains.

“Once they understand what the patient’s treatment plan is and the patient’s transitional care needs, they make certain all follow-up appointments are made, and they keep the patient’s physicians well informed,” she adds. “Within 24-48 hours, they make a follow-up phone call to the patient and make sure the patient understands his or her medicine and the health treatment plan and that everything is aligned.”

The following is a typical transitional case management scenario:

Day of hospital admission: “The minute a patient is registered and is one of our physicians’ patients, a HIPAA-compliant text is sent to TCM, notifying us of the patient’s name, diagnosis, and the patient’s primary care provider,” Vanaskie says.

The case manager meets the patient, hands out a business card, and makes sure the patient clearly understands there is a representative from the primary care office who will stay involved in the patient’s care, she explains.

“The case manager says that if the patient needs anything, she’d be happy to help coordinate it while the patient is in the hospital or when the patient returns home,” she adds.

During hospital stay: The transitional case manager visits the patient each day of the hospital stay. When the hospital’s tests and lab results are available, the TCM will send those to the primary care physician and meet with the patient to discuss further discharge planning. The transitional case manager also meets with the hospital case managers to go over the discharge plan, Vanaskie says.

The TCM informs the patient’s community providers about all procedures and tests, and reports back to the hospital team any concerns the primary care providers might have, she says.

“They try to bridge that communication link between hospitalization and primary care,” she says. “Having a HIPAA-compliant texting system allows us to attach documents so when we get a document or lab report we can send it right over to the PCP.”

Patients’ community providers are able to follow the patient’s hospital care and treatment and provide information and input as necessary, she says.

“We often bring to the table long-term care needs that the hospital case manager won’t have,” she says. “The primary care physician is a valuable player to the hospital team because they have such a defined scope of knowledge.”

Day of discharge: The TCM makes sure everyone is aligned on the patient’s day of discharge, Vanaskie says. TCMs reinforce to patients that they’ll be calling the patient at home. They follow up with the call and listen to any concerns the patient or caregiver has. When needed, a licensed clinical social worker (LCSW) care coordinator will make a home visit.

“We wrap our arms around that case until they feel more secure,” Vanaskie says.

As the patient is discharged, the TCM keeps community doctors updated on what is going on, she says.

Post-discharge. As a case manager learns more about the patient’s issues and concerns post-discharge, the TCM can help the patient resolve barriers to maintaining health. For example, if a patient’s chief obstacle to making follow-up doctors’ appointments is lack of transportation, the TCM will link the patient to a free transportation service provided by a community-based organization, Vanaskie says.

The same is true of other needs, including dietary guidance, caregiver respite, grocery shopping, and companionship, Vanaskie says.

TCMs also provide follow-up medication reconciliation: “The hospital does the majority of medication reconciliation, but when the patient comes back to their primary care provider for the first doctor’s appointment, we can do medication reconciliation by phone,” she explains.

“We make sure patients have their medications, and we answer any questions about it,” she says. “We also have them bring all of their pills to their doctor, including vitamins.”

This quick medication reconciliation phone call helps TCMs identify any new problems, she says.

“You’d be surprised how many patients said they didn’t like the copay and wouldn’t pick up their medications,” Vanaskie notes. “The TCM might find out the patient didn’t understand their medication instructions or that there was a discrepancy in the prescription.”