“Communicate, communicate, communicate,” should be the mantra of all case managers, says Jean Maslan, BSN, MHA, ACM, CCM, senior managing consultant for Berkeley Research Group, with headquarters in Emeryville, CA.

In the hospital setting, this means the inpatient case managers should communicate amongst themselves, with the patient and family, and the nurse navigator, who, in turn, communicates with patients and everybody involved with them after discharge.

“That is the hurdle that inpatient case managers need to overcome. The nurse navigator is the communication link between the hospital and the community. Inpatient case managers need to understand the importance of the role and work closely with the navigator,” she says.

Maslan envisions the transition case manager or nurse navigator as part of the case management department, and who will collaborate with physicians, the rest of the team, and the community to provide support for patients when needed.

Communication with the inpatient case managers and participating in multidisciplinary meetings is crucial, she adds. “Nurse navigators have to be part of the whole inpatient care team so they understand everything that is going on with the patient. Inpatient case managers can look to the nurse navigator as an expert in community resources that could help patients after discharge,” she says.

While they work side-by-side with inpatient case managers to develop the plan of care, the nurse navigators should be building a relationship with the patient and family, Maslan says.

“We want patients to call the nurse navigator when they are back in the community and having problems. The nurse navigator may be the person to stop patients from going back to the emergency department by connecting them with the right services in the community, which for many patients starts with the physician’s office,” she says.

The biggest gaps in care occur as patients transition from the hospital and back into the community, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts. “Communication between case managers across the continuum to coordinate care for patients at highest risk is essential,” she adds.

It’s always helpful if someone performs an assessment in the patient’s home to discover any problems the patients are having or issues that weren’t uncovered during the hospital stay, says Sharonne L. Lynch, LMSW, CCM, former director of social work at ArchCare at Terence Cardinal Cooke Health Care Center in New York City.

“When patients are in the hospital setting, the nurses, doctors, and other clinicians are taking care of them. When the patient is home, it’s a whole new ball game. They have all those bottles of new medication, pages of discharge instructions, and it can be overwhelming. When a nurse or social worker visits the homes, they can see the conditions and patient support system firsthand and correct any problems,” she says.

Nurse navigators are the key to improving post-discharge communication and helping patients stay healthy in the community, Maslan says. “The nurse navigators have to go out in the community and visit patients in their homes to see their living situation firsthand. They may need to attend physician visits with the patient so they can explain the treatment plan,” she says.

An important duty for transition case managers is to make sure the patient is linked to an appropriate care provider and that the provider has the information needed to pick up care of the patient without gaps, says Beverly Cunningham, RN, MS, consultant and partner at Oklahoma-based Case Management Concepts.

For instance, in the case of complex patients being discharged to home, the transition case manager should communicate with the case manager in the patient’s medical home.

Other examples of the transition case manager’s outreach include making periodic calls to a skilled facility to check up on patients covered under the bundled payment program for hip fractures, checking with a cardiac rehab provider to find out how myocardial infarction patients are tolerating rehab, and intervening with patients who haven’t been participating in the program.

Community-based case managers, who may be nurses, social workers, or trained lay workers, can be a good resource for some patients transitioning to the community, Cesta points out. The community case managers could be in a medical home, a physician office, a federally qualified health center, or be part of an accountable care organization, she says.

They can provide valuable help in working with the transition case manager to help patients move from the hospital to home and then assist them in navigating through the healthcare continuum, Cesta adds. Not every patient qualifies for community case management. It depends on the patient’s source of funding or lack of funding, Cesta points out.

Case managers at the patient’s insurance company can also help with transitions, Lynch says.

“A lot of insurance companies are now starting to see the effect of patients falling through the cracks and they are assigning care managers to follow them after discharge,” Lynch adds.

She recommends that case managers who are coordinating post-discharge needs for patients collaborate with the insurance companies to share information and avoid duplication of services.

“The insurance company case manager is the one person who stays with the patients, whether they are in the hospital, a rehab facility, or a skilled nursing facility. Patients may have different case managers and social workers as they move through the continuum, but in most cases they continue to have the same insurance case manager,” she says.