If your hospital doesn’t have its own community-based workers to support at-risk patients, you should research the providers in the community and what services they can offer, advises Donna Zazworsky, RN, MS, CCM, FAAN, principal of Zazworsky Consulting in Tucson, AZ.

“When they work with patients who are at risk for readmissions or additional healthcare costs, case managers should get their high-risk patients into a system where there are trained people who can work with them and follow them until they can manage on their own,” Zazworsky says.

This may be a large medical group, a community clinic, or a community service organization, Zazworsky says. “But many times, case managers on the unit don’t know that care coordination services in the community exist,” she adds.

“A lot of times, when case managers arrange follow-up appointments with primary care providers or specialists, they consider only locations where they can get the patients in quickly,” Zazworsky continues. “If their office doesn’t have the ability to support at-risk patients in the community, the patients are likely to bounce back to the hospital.”

Zazworsky recommends that case management directors set up meetings with the community organizations that can provide assistance to their patients after discharge.

“Identify key point persons and the referral process. Most importantly, ensure that the hospital will get feedback to show that the baton was successfully handed off,” she adds.

Where does one find someone in the community to manage discharged patients?

Community-based case managers are most often found in patient-centered medical homes or health homes, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

Accountable care organizations hire them to coordinate care across the continuum, she adds.

“I see more and more primary care providers taking on the community outreach role,” Zazworsky says. “Physician practices operate on small margins, but if they can meet the criteria, they can be reimbursed by using the chronic care management and transitions in care codes,” Zazworsky says.

In addition, some commercial health plans are offering grants to providers to set up a care management program.

Federally qualified health centers and other community health centers often have eligibility workers, chosen for their communication skills and trained to determine if patients are eligible for Medicaid, help them enroll, and assist in accessing other community services, she adds. “The patients may be handed off to a person with a higher level of training if they need help over the long term,” she says.

The type of programs available are very population-driven, Zazworsky points out.

For instance, organizations that work with the homeless are likely to have a community outreach worker, probably a lay person, who connects the homeless with supported housing and other community resources, she says. In the Tucson area, recovery coaches within behavioral health agencies work with Medicaid beneficiaries to help them work on recovery and to access other community resources, Zazworsky adds.

Cesta advises case managers to work with their hospital’s information technology staff to automate the process of risk stratifying patients. Each hospital should determine its own parameters, she advises.

Include a patient registry that flags patients when they miss an appointment or a test, or when they have an abnormal lab result, she suggests. With high-risk patients, take a proactive approach and give them the support they need to follow their treatment plan, she says.

A hospital’s readmission prevention program and/or transition program should encompass the entire continuum and link the hospital team to the transition care coordinator, home health services, post-acute providers, and the community at large, Cesta says.

As providers move toward population-based care, hospitals have an opportunity to partner with community-based organizations to coordinate care for the patients they serve, Zazworsky says.

Hospital EDs are one area where community outreach workers can be effective, she adds. “That’s where the homeless, the uninsured, and patients without a primary care provider come for treatment. There is a lot of value in having someone who can connect these patients to a primary care provider and help them sign up for disability insurance, Medicaid, or other funding and support resources,” she says.