Even if your hospital has little or no financial risk for what happens to patients after treatment in an acute care setting, case managers should connect with community organizations that provide the types of resources your patients need, says Cheri Bankston, RN, MSN, director of clinical advisory services for Curaspan.

“Hospitals should start collaborating with community organizations now so they’re prepared for the transition. Case management departments should expand their database of community resources and reach out to the entities in the community to find out what services they provide and how to make referrals,” she says.

Start by assessing community resources and the population you are trying to serve and identify any gaps in services, she says.

Bankston suggests organizing a group of stakeholders, including hospital leadership, case managers, and even local payers, to look at the gaps and find ways to fill them.

If you identify gaps in service for a particular population, look for a solution. “This is where hospitals get creative. Some hospitals are partnering with the local emergency medical services, churches, or Area Agencies on Aging,” she says.

In order to ensure that patients who don’t have a primary care provider have a follow-up appointment and continuing medical care, Donna Zazworsky, RN, MS, CCM, FAAN, principal of Zazworsky Consulting in Tucson, recommends working with the major primary care providers in the area, including large physician groups, federally qualified health centers, rural health clinics, and any other organizations that provide primary care.

Compile a list and determine the chief contact in those organizations and who from the hospital should meet with them, Zazworsky suggests. “While the case managers are the ones the hospital case managers will be working with, they aren’t necessarily the decision-makers in the organization,” she points out.

She suggests that the director of case management in the hospital initiate a meeting with the chief executive officer, the chief operating officer, or the medical director of each primary care provider to open the dialogue. “In some cases, it may be more effective for the chief medical director of the hospital and the chief medical director of the primary care practice to meet,” she says.

Before the meeting, identify the high-risk patients who are potential readmissions and compile data on the number of patients and their discharge needs.

“Point out that these individuals don’t qualify for home health but have a high rate of readmissions, and brainstorm on what kind of program could be set up to provide care,” she says.

“It’s been my experience that primary care providers are very happy to have a working relationship with hospitals. It’s a matter of developing a flow of processes and how referrals would work,” she says.

When Zazworsky helped create a partnership between a hospital and a federally qualified health center to provide coordinated care after discharge for appropriate patients, case managers from the health center and the hospital created a flowchart of how the program would work. They included details such as what kind of patients were appropriate and how the case managers at the health center would be notified.

The federally qualified health center placed its own physician at the hospital where he serves as a hospitalist. The physician treats the patients in the hospital and assists with transitions of care, she says.

Volunteers from local churches provide support and education for low-income patients with chronic conditions who are being discharged from the hospital in a model program, Zazworsky says. The program originated in Memphis, but similar programs are cropping up all over the country, she adds. The volunteers go through training that includes information about the disease and tips on how to interact with patients. They visit patients in their homes and make sure they have everything to meet their medical and psychosocial needs. (For more details on one program, the Congregational Health Network, see the April 2015 issue of Hospital Case Management.)