Patients’ chronic conditions increasingly can be managed at home, but it requires highly effective communication between providers — and this is where case managers can help.

“We can manage patients’ chronic conditions in their home environment — the least restricted environment — and keep them in an optimal state of wellness, enhancing their quality of life and managing costs,” says Patricia Hines, PhD, RN, managing director for care management transformation at Novia Strategies in Poway, CA.

A key strategy in improving communications is the SBAR, which was created by clinical staff at Kaiser Permanente in Colorado:

S = Situation;

B = Background;

A = Assessment;

R = Recommendation.

SBAR is a communication framework between healthcare team members. It gives clinicians a way to focus expectations and attention to particular issues.

“Using SBAR, when a physician comes to the phone, the case manager can give the information that’s needed, providing a good assessment around what should be done next,” Hines says.

The SBAR toolkit can be found on the Institute for Healthcare Improvement’s website. “Take that toolkit and learn about SBAR,” she says. “Write out what’s a situation, background. Writing it out helps to think about it.”

Communication strategies should be directed to particular physicians and disciplines. For instance, case managers in the hospital environment often are working with hospitalists, so their communication plans should be directed to hospitalists.

“It’s typical that each is seen by a case manager who will identify what the patient’s plan of care is, know what the patient’s payer source is and the benefits associated with that, and from a social worker perspective, understand what’s going on in the home environment,” Hines says.

“I think it’s all around the communication style, and it’s a way in which you present to the physician,” she adds.

Instead of saying, “Don’t you think we should do X?” a case manager could say, “I noticed the last time the patient had this situation, you did Y. Do you think that would work again at this point?” Hines suggests.

“If you have a suggestion or recommendation, then you can bring that information forward and engage with the physician in a way that’s helpful and not aggressive,” she adds.

Handoffs are where clear communication is especially important.

For example, when the hospitalist is discharging the patient to the skilled nursing facility (SNF), then communication between the hospital and SNF should include the next level of care requirements. These go to the medical director or whoever is caring for the patient. The handoffs are important in terms of medication reconciliation, Hines says.

“Case managers dealing with physicians at the hospitalist level could engage in daily bed huddles or rounds with the multidisciplinary teams,” Hines says. “The way the team engages with the hospitalist is being able to be there as a team and collectively talk about what the patient’s plan is for care treatment, discharge barriers.”

Case managers could find out how a particular physician likes to receive communication and contact them with the preferred method. “Some physicians are more open to electronic communications or want to receive phone calls,” she says.

Some physicians will include case managers on the team, so communication is direct.

“When we get into primary care physician [PCP] offices and if we have an embedded case manager, the case manager is helping the physician manage the patient’s care,” Hines says. “So if the patient has comorbidities and is being seen by the PCP, then the case manager might do weekly or biweekly calls to the family to talk about how care is being provided.”

The case manager calls also involve weekly or biweekly family calls to discuss how care is being provided. “They make sure they’re doing well and have the medications they need, so we don’t end up with the patient having exacerbated chronic obstructive pulmonary disease on Friday morning and ending up back in the ER,” she adds.