Don’t base referrals to the complex case manager strictly on the age of the patient or the diagnosis, cautions 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 case manager in this role must focus on patients with any complicating factor, whether it’s medical, psychosocial, behavioral, poor compliance, or any combination of factors. These can affect patients of any age,” Rossi says.

She recommends developing an in-depth assessment that captures the patient’s current and previous level of illness and injury and functional ability. Include areas such as polypharmacy issues, psychological or mental health issues such as depression, the potential for falls, psychosocial and economic needs including a poor social support system, and potential caregiver burnout. Include questions on use of resources before admission, the patient and family’s perception of the illness or injury, the home environment, and the ability of the patient and family to afford the copay for any care or services the patient will need. She suggests an initial assessment and reassessment as the hospital stay progresses.

“The complex case manager should use the information gleaned during the assessment and reassessment to develop discharge Plan A and discharge Plan B in case Plan A doesn’t work. In some cases, Plan C may be needed,” she says.

When the patient is ready for discharge, it’s imperative for the complex case manager to ensure the patient has follow-up appointments, transportation to those appointments, and that information on the hospital stay is shared with the post-acute medical treatment team. The providers at the next level of care should have a copy of the discharge summary, and the case manager should communicate any key issues to the receiving clinician.