The role of transition coordinator may be a new one, but it will take an experienced case manager or social worker to handle it successfully, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.

“The title and job description for the person who handles transitions will vary from hospital to hospital, but one thing is certain: The person in that position needs to be an experienced professional, either a case manager or a social worker,” Cunningham adds.

A transition case manager should have acute care experience and understand how the hospital works and how to connect patients from the hospital and the next level of care, Cunningham says.

It takes a special type of person to coordinate transitions for patients with complicated needs, points out Peggy Rossi, BSN, MPA, CCM, continuity of care service director for Kaiser Permanente Sacramento Medical Center and consultant for the Center for Case Management.

“The job is fast-paced and requires a concentrated effort. It’s a lot of work for one person. The right person for the job has to be able to work quickly and efficiently to develop the discharge plan,” Rossi adds.

Candidates need to have experience in coordinating care for complex patients, understand payer rules and regulations, and be well-versed on what organizations in the community can provide, Rossi says.

“Professionals in this position need to have extensive knowledge of community resources and how to make a referral. They need to know when to make a referral for palliative care and when to get other team members involved,” Rossi says.

Depending on the hospital’s patient population, the role could be filled by an RN or a licensed social worker, Cunningham says.

In smaller hospitals, the role could be combined with the complex discharge planning role, but in most cases, it should be a separate role, she adds. “The job requires an experienced professional. A new nurse or social worker just exposed to acute care doesn’t have the knowledge needed to be successful in the role,” Cunningham adds.

The job of the transition case manager should be a stand-alone role and not combined with other duties, adds Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

“Transition case managers shouldn’t handle the day-to-day case management tasks, but should work with the unit case manager as a member of the team but have a distinct set of functions,” she says.

Hospitals have to develop a detailed job description for the nurse navigator position and lay out specific tasks the navigator will or won’t be doing, Cesta says.

“It’s easy for the roles to blend. That why it’s critical to have a detailed job description that identifies the responsibilities of the role and when the transition case manager gets involved,” Cesta says.

Caseloads for transition case managers should be lower than those of the regular case managers so they’ll have time to focus on the patient with complex needs, Rossi adds.

“Depending on the intensity or the complexity of the medical needs, some days the caseload might be 10 patients but on other occasions, the case load may be even lower,” she says.

Rossi adds that transition case managers may need to work different hours from the traditional 8 a.m.-to-5 p.m. schedule many case managers follow. She suggests having the complex case manager work 11 a.m. to 7 p.m., or noon to 9 p.m. Monday through Friday.

“This will allow the case manager to have the flexibility to be available to work with families when they visit the patient after work,” she says.

The concept of a transition case manager is still very new and it may take a while to sort out what the role will entail, Cesta says.

The details of the job may differ from hospital to hospital, but there is all one goal: ensuring that discharged patients have the services and support they need to avoid readmissions and/or ED visits, she adds.

The transition case manager in the hospital setting is typically a nurse who follows patients who are discharged to home with or without additional services by telephone for 30 to 90 days, Cesta says. The transition case manager doesn’t necessarily follow patients going to a skilled nursing facility or a rehabilitation hospital, she says.

“The point is to make sure that patients who are discharged to home receive the services specified in the discharge plan, to answer any questions they have, and identify medical problems and take action before they escalate,” she says.

In the beginning, the person in the new role and the existing case managers may bump into each other, Cesta says. To avoid duplication of services, educate the rest of the staff on the role of the transition case manager and their function on the team, she adds.

For instance, if a patient is still in the hospital, the regular case manager and social worker can never take a hands-off approach. They should collaborate with the transition case managers and stay involved with the patient, Cesta says.

The case management leadership should lead the effort to develop criteria for referring patients to the transition case managers. Depending on the hospital’s patient population, patients could be identified by specific diagnoses, the number of hospital admissions, ED visits or readmissions, or amount of resources used, Cunningham suggests.

Create a dashboard so everyone is fully aware of what is going on. Include how many discharges the transition case manager handles each month, where the patients went, how many days they stayed in post-acute facilities, readmissions, and other outcomes metrics, Cunningham suggests.