Case managers can’t create good patient flow alone — it takes a team. The following are some tips from the experts on how you can work with patients and families, physicians, other members of the hospital team, and post-acute providers to move those patients along efficiently and safely.

Develop relationships with your counterparts in other settings. Whether home health agencies or skilled nursing facilities are part of the health system, hospitals need to develop relationships with post-acute providers to provide more cross-continuum care options, says Connie D’Argenio, MS, BSN, managing director of Huron Healthcare Practice at Chicago-based Huron Consulting Group. “By developing alignment strategies with post-care providers, case managers can arrange services and transitions to another level of care directly from the ED,” she says.

When traditional inpatient case managers have a relationship with their counterparts in other settings, they can share information — resulting in excellent care across the continuum, says Mark Krivopal, MD, MBA, vice president at GE Healthcare Camden Group, based in Boston.

“The patients benefit because they get better and more efficient care, the hospital benefits from improved patient flow and a reduction in time spent reinventing the wheel, and physicians benefit because they can focus on clinical care,” Krivopal says.

Develop creative solutions to the practice of premature admissions. “I see avoidable days happening across the country when patients come in a day early because of psychosocial issues, and the providers admit them rather than lose the time secured for the intervention if the patient doesn’t show,” says Mindy Owen, RN, CRRN, CCM, principal owner of Phoenix Healthcare Associates in Coral Springs, FL, and senior consultant for the Center for Case Management.

This means that the hospital is essentially providing free care for the day before the scheduled procedure and the patient is taking up a bed that could be available for a patient whose stay will be reversed, she adds.

Some hospitals have a fund to pay for a hotel room for patients who live too far away to make the trip the morning of the procedure and provide taxi vouchers for patients who have transportation issues, she says.

The practice indicates a lack of understanding about admission criteria and medical necessity, and the case manager should provide education for the admitting physician, she adds.

It takes a change in hospital culture so everyone on the staff will understand what a higher level of care is designed for and what doesn’t qualify, Owen says. “Until there is a change in the healthcare culture, we are going to see pockets of avoidable days,” she says.

Develop clear milestones that indicate a patient is ready to move to the next level of care. D’Argenio suggests the interdisciplinary team determine the milestones based on clinical pathways, or decide on the milestones for each patient during rounds. A milestone might be converting to oral medication from IV medication, ambulating a certain distance, or being able to perform a certain activity without oxygen, she says.

The team should focus on the milestones during interdisciplinary rounds to determine the plan of care for the day, and share the milestones with patients and family members. “When the family understands the milestones the patient needs to achieve to move forward, they can become a partner in the progress,” she says.

Hold interdisciplinary rounds every day. If your hospital doesn’t have daily interdisciplinary rounds, you’re missing an opportunity to work with the treatment team to create a plan for each patient, identify delays in moving the plan forward, and work together to overcome the delays in real time, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

Case managers on the unit should be active members of the interdisciplinary care team and interact daily with the treatment team to ensure that the patient progresses toward discharge, D’Argenio adds. “All members of the care team should be knowledgeable about and engaged in the discharge plan, including the patient and family,” she says.

D’Argenio recommends that interdisciplinary rounds include that patient’s physician, nurse, case manager, and any appropriate ancillary provider such as physical therapists, respiratory therapists, and pharmacists.

During the initial meeting about the patient, the team should go over the assessment and preliminary care plan, set a potential discharge date, and determine what needs to happen to accomplish a safe discharge. The case manager should write a summary of the meeting, including the goals, and note any delays, Owen says.

The team should reassess the patient and update the plan every day to move the patient toward the discharge, she says.

“Starting from the point of admission, everyone on the treatment team, the patient, and family all need to be on the same page. The team should determine what needs to be achieved each day and what the next milestone will be,” D’Argenio says.

Determine a discharge target and keep the family updated. Family decision-making, particularly in end-of-life situations, is also a major cause of avoidable delays, Cesta says. “Some delays occur partly because the case managers don’t start talking with the family early on. Often this is because of staffing restraints. Case managers and social workers need to work on flex time so they will be available to family members when needed,” she says.

Case managers should keep patients and family members informed about where patients are in the treatment plan and update them regularly on the expected discharge date, says Bonnie Barndt-Maglio, PhD, RN, managing director at Chicago-based Prism Healthcare Partners.

Make sure the estimated day and time of discharge is written on the white board in the patient’s room on the day of admission and updated throughout the stay so everyone on the team, as well as the patient and family, are aware of it, she adds.

There may be push-back from the interdisciplinary team because of reluctance to estimate a discharge date, she says. “We, as medical professionals, were educated that if you aren’t 100% sure, don’t write it down. But in the case of the estimated day of discharge, it’s a goal and the case manager should make that clear to the patient and family,” she says.