Transitions of care can be difficult if case managers fail to prepare for some of the more common obstacles and problems.

  • Case managers need to guide patients and caregivers when they make decisions about the next step.
  • Above all, keep patients and caregivers informed of what’s going on and when a care transition will occur.
  • Listen, nonjudgmentally, to patients’ and caregivers’ concerns and goals.

As case managers provide the emollient that keeps the healthcare system’s care transitions in motion, there are some common pitfalls they need to avoid.

“There are pitfalls that occur during transition of care, and they take place whether patients go from the hospital to a skilled nursing facility [SNF] or SNF to home health, wherever they’re transitioning,” says Richard Lasota, RN, CCM, director of business development for the Southwest division of Life Care Centers of America in Phoenix.

“There are things we take for granted and things we do as care managers that don’t work well for patients,” Lasota says. “We need to focus on the top four or five things that we run across in our day-to-day lives that cause patients and families a little bit of heartache.”

Lasota lists the top care transition pitfalls, as follows:

Helping patients make informed decisions. Often it’s the case manager’s role to guide patients and their families into making decisions about the next steps in their healthcare journies. But this moment often is shortchanged, Lasota says.

“So many times in the healthcare industry we talk about freedom of choice and how people need to have choice,” he says. “But what happens 90% of the time is the case manager will come up to a patient and family at the last minute and say, ‘Hey, you have to go to a skilled nursing facility, so here’s a list.’”

The list might have 30-plus facilities, which is no better than handing someone a phone book, Lasota says.

“It doesn’t take into consideration that patient’s condition, what type of care the patient needs, or what the facility is rated,” he says.

Instead, case managers should begin discussions about care transition much sooner, giving people time to visit facilities and to check Medicare star ratings of each site, he suggests.

When case managers give people choices without giving them the kind of information that’s necessary to make an informed decision, then it will result in frustrated patients and families, he says.

“You have to figure out a way to provide not just a list, but also some guidance that will help people make a more educated decision,” Lasota says. “Have some set of criteria to help guide that person.”

Criteria could include Medicare star ratings and information about the types of services the next site could provide. For instance, if the patient needed a specific health service and many providers did not have that service, those sites could be eliminated from consideration, he says.

“If you hand patients a stack of brochures, then all you’re doing is having them pick the facility with the best graphic art designer and not the facility that will meet their needs,” Lasota says.

Keep patients’ families/caregivers informed. When case managers are dealing with patients who have involved family members or caregivers, it’s important to keep them in the loop with changes and decisions. Poor communication can lead to major problems for the people involved, Lasota notes.

“One woman I worked with had a husband in the hospital for four days, and while she was at work, someone called to tell her that in two hours her husband would need to be picked up and taken to a skilled nursing facility,” Lasota recalls. “These are situations that are just wrought with bad choices and having a bunch of people scrambling around, trying to get the patient transferred.”

Other situations might include a community case manager assisting a patient in seeing a new provider who orders new therapy, but no one tells the patient’s family. When the family visits the patient, they are surprised by seeing strangers in the home.

It’s always a good idea to let patients’ caregivers know what is going on, when changes will occur, and whether there is anything they need to do to facilitate the new healthcare services, Lasota says.

Speak with words patients and families can understand. “When we talk with families and patients about their transition of care, we have to be careful to speak in a language that the patient and family understand,” Lasota says.

Avoid abbreviations, medical terms, and jargon, he suggests.

“It can confuse people and, unfortunately, a lot of adults won’t ask questions,” he adds. “They’ll kindly sit there and smile and nod at you, so you have to explain things in a way they can understand.”

Case managers also can ask patients and caregivers to repeat back what they’ve said and then correct any misperceptions.

“This will cut down on their frustration and anger,” Lasota says. “It’s a simple thing and takes an extra minute, but that extra minute is well spent.”

“Listen with our ears and not our mouth.” Patients can tell case managers what they need and want, but someone has to hear them, Lasota says.

“How many times do we have a preconceived idea of what the plan should be for the patient, and we’re not even listening to the patient?” he says. “Listen to their concerns, listen to what they’re trying to say, and then have a conversation with them.”

Case managers will know patients’ fears and anxiety after spending time with them, and then they can help them make better decisions, he adds.

The goal is to do what case managers already do best: Think outside the box. Maybe one particular plan would work best for a patient, but if the patient has another idea, then it’s time to think of an alternate way to achieve the same positive health outcome. For example, perhaps a patient would do well in a skilled nursing facility, but if the patient wants to go home, then maybe family members or a private duty nurse could care for the patient as well, Lasota says.