Communication is one of the biggest shortcomings of today’s health system — and it’s getting worse, states BK Kizziar, RN-BC, CCM, owner of BK & Associates, a Southlake, TX, case management consulting firm.

One culprit is the trend toward point-and-click documentation, she says. Adding information to the medical record by checking off boxes saves time, but it doesn’t give a true, comprehensive picture of the patient, she adds. Even if the documentation is comprehensive, providers in other levels of care may not have access to it, she adds.

“Nothing can replace face-to-face communication or at least phone communication with the next level of care, but I’m seeing less of that. But as hospitals become at risk for post-discharge periods, they are going to have to enhance their communication with post-acute providers. Good communication with the next level of care is going to have to be a standard of practice for case managers,” she says.

Case managers should talk to their counterparts at other levels of care about psychological and social issues as well as medical issues, she says.

“Providers at all levels of care have skin in the game to keep the patient well and on a better path. Case managers need to look at care across the continuum and have conversations with everyone who cares for the patient after discharge,” says Donna Hopkins, MS, RN, CMAC, vice president at Novia Strategies, a national healthcare consulting firm.

Build relationships with your counterparts at all levels of care and community organizations and share information about patients and their care plans, she advises.

“A synergistic partnership will result in better outcomes for the patient,” she says.

Case managers in accountable care organizations (ACOs) should initiate a multidisciplinary conference across all the entities providing care and work with them to create a work flow that eliminates duplication, Hopkins says.

It’s more difficult when patients are not in an ACO and providers aren’t part of the same healthcare system, she adds.

“The challenge is to determine who is in charge and to coordinate all those touchpoints,” she says.

Work with your counterparts at organizations to eliminate the duplicative follow-up telephone calls that annoy patients and family members, Kizziar says.

Patients may receive follow-up calls from the care manager in the medical home, someone from the home health provider, the hospital case management staff, someone from a community agency, and their payer’s case management team, she points out.

Having a multitude of case managers making follow-up calls is very irritating to patients and families, Kizziar says. “They end up telling the same thing to three or four different people, and some just stop answering the telephone,” she says.

Hopkins recommends tracking all post-discharge calls. Write down whenever calls are made to patients and family during the episode of care, usually three to four months. Then work to eliminate duplications.

She recommends developing scripts for the follow-up calls, and those making the calls document them in the medical record so everyone involved with that patient can access the record and see that the calls have been made.