Hospital case managers should create alliances with primary care providers who can share information that will help in creating a discharge plan, according to the chief executive officer of El Rio Community Health Center in Tucson, AZ.

• El Rio has developed a patient portal through which the health center staff and staff at three health systems share information to help patients get the care they need and create smooth transitions.

• Information on patients’ behavioral health issues is also on the patient portal so clinicians at all levels of care will be aware of potential roadblocks to care.

• The health center staff has regular meetings with skilled nursing facilities and home health agencies, and the next step is to include hospital case managers to work on ways to smooth transitions between all levels of care.

Hospital-based case managers don’t have to start from scratch when they are gathering information on a new patient, says Nancy J. Johnson, RN, PhD, chief executive officer of El Rio Community Health Center in Tucson, AZ. The case manager at the patient’s primary care office probably can provide everything needed to develop a successful discharge plan, she adds.

“The health home staff knows a lot about patients, and with today’s technology, it’s easy to connect hospital case managers to the case managers at primary care providers,” Johnson says. El Rio is a federally qualified health center and Level 3 patient-centered medical home.

El Rio’s 11 campuses provide care for 95,000 patients, ranging from patients with no insurance to those who are fully insured, including about 60% of the center’s 1,100 employees. About 54% of their patients live below the federal poverty level.

The health center has shared patient information with three Tucson health systems, with a total of five hospitals, for years through patient portals accessed by clinicians at both levels of care. “Our nurse care coordinators have a collegial relationship with the nurse case managers in the hospital and share information that will help them manage the care of patients in the hospital. In turn, they inform us when our patients are hospitalized and when the transitions in care occur,” she says.

Sharing information has been helpful in getting the patients the care they need and, as a result, patients from the health center experience one of the lowest readmissions rates in Arizona, Johnson says.

The health center has a centralized team of RN discharge coordinators who access the internet portals of local hospitals each day and identify El Rio patients who have been admitted to the hospital or have been to the ED.

The centralized nursing team passes the information on to the organization’s RN care coordinators, who are located at the health center’s 11 campuses. The care coordinators at the individual campuses take on accountability for the patients that have been treated at their facility.

“They try to make contact with the patient or family before patients leave the hospital. These conversations are a good time for the care coordinators to identify a patient at risk, such as those who are socially isolated or frail, and get them into our discharge clinic as soon as possible,” Johnson says.

They determine what caused the admission, what is happening during the hospital encounter, and when the discharge is likely to occur. They follow up by phone after the discharge and make sure patients have filled their prescriptions, that any assistive device or other equipment has been delivered, and that they have adequate support at home.

The nurses contact patients who have visited the ED for non-emergent problems and coach them on the appropriate level of care. They remind patients that the health centers are open on evenings and on Saturdays and inform them about the triage telephone line.

“Many of the patients who are frequently hospitalized or visit the emergency department have behavioral health issues. We have integrated behavioral health with medical care and dental care in our centers to give patients a holistic healthcare experience. All the data is in our shared electronic medical record. We’re all on the team and we pull together to provide excellent patient care,” she says.

El Rio Community Health Center began its alliances with local hospitals as some of its physicians began providing care at one Tucson hospital and instituted telephonic rounds between the hospitalists and nurses at the community health center. “It worked extremely well. We were able to share information and not have to reinvent the wheel. The nurses at both levels of care have enjoyed bridging the connection between the hospital and the community,” Johnson says.

The health center reached out to each Tucson hospital to set up electronic health record access and to take care of details involved in meeting HIPAA requirements.

El Rio invited case managers from skilled nursing facilities, home health companies, hospitals, and the health center’s team to talk about coordinating care and how to perform a warm handoff. The group continues to meet on a regular basis.

The RN care coordinators at the health center also share information with the home health nurses caring for their patients.

The next step is to build alliances to facilitate smooth transitions between the hospital, skilled nursing facilities, and the health center’s clinics.

“It’s important for us to know when patients leave the hospital if they are going to a skilled nursing facility so we can make the connection and be notified when the patient is going home,” Johnson says.

Johnson advises hospital-based case managers to build a relationship with the largest primary care provider in the community, whether it’s an independent practice, a group affiliated with the hospital, or a federally qualified health center. “Most hospitals have some kind of relationship with physician groups. This would be a good starting point for creating connectivity,” she says.

Find out who is responsible for care coordination and develop ways to share information about patients. You may not be able to share medical records at first, but you could fax each other or communicate by phone, she says.

Take the opportunity to bring care managers from other levels of care together for joint education and to brainstorm on ways to provide smoother transitions, she suggests.

“When all the providers who take care of patients share information, it’s very powerful and results in better patient care,” she says.