Every hospital has a subset of complex patients whose discharge needs take all of the case manager’s or social worker’s time for a day or longer, says Toni Cesta, RN, PhD, FAAN, partner and consultant in North Bellmore, NY-based Case Management Concepts.

When Cesta was a case management director, she added a new role to her department. The purpose of the position was to coordinate the discharge for complex patients and free up the rest of the team to handle their day-to-day activities and routine discharges.

That was in the late 1990s, and the need for such a position is even more acute today, Cesta says.

The changes in healthcare reimbursement and the increase in patients with complex needs and inadequate or no funding have created a huge workload for case managers and social workers, adds Cheri Bankston, RN, MSN, senior director of clinical advisory services for naviHealth, a Cardinal Health company.

“Case managers get so busy with day-to-day work that it’s hard to find time to stop and come up with a comprehensive plan, or they spend so much time on a complex discharge plan that their other tasks fall by the wayside. That’s why hospitals need someone who can coordinate the discharges of patients with complex needs and/or no resources,” she says.

The person in the role may be called a discharge planning specialist, a complex case manager, a transition nurse, or have another designation, Cesta says. “There may be different titles, but it’s all about identifying the time-consuming patients and making one person responsible for their discharge, she says.

The position can be filled by a nurse case manager or a social worker, depending on the types of patients that present discharge challenges, Cesta says. A skilled discharge planning specialist can effectively handle up to 15 patients at a time, Cesta says.

Another role that can help with discharges is the discharge advocate, who could be unlicensed staff or a lay person, depending on how the individual hospital defines the job, Bankston says. His or her responsibility is to meet with patients and family members and make sure they understand the discharge instructions, have transportation, set up a follow-up appointment, and follow the patients as they navigate the post-discharge healthcare system.

The staff should refer cases to the discharge planning specialist when the routine discharge process isn’t going to work and someone needs to dig in on the case, Cesta says.

To improve processes, develop criteria for the cases that should be handed off to the complex case manager, Bankston says. For instance, ventilator and dialysis patients, those with difficult families, undocumented immigrants, patients with no insurance, instances where a guardianship must be established, and patients whose families are in another state or country might be among the patients referred to the complex case manager, she says.

Case management leadership should educate the staff on what kinds of cases should be referred to the discharge planning specialist, she says. Another source of referrals is a long-stay meeting during which a multidisciplinary team reviews patients with lengthy stays.

“The staff’s level of understanding of what kind of cases should be referred is very important. You don’t want to waste the specialist’s time,” she says.

Cesta recommends filling the position with a person who has three to five years’ experience as an acute care social worker and experience with complex discharge planning.

Look for someone with excellent clinical and administrative skills and judgment, she recommends. Other criteria should be strong interpersonal and communication skills, and the ability to work effectively with other disciplines and departments, including the hospital’s finance office, legal team, and, in some cases, foreign embassies and the police.

“Candidates for this role should be among the department’s most experienced staff and have a good relationship with physicians and community providers. They should have good communication skills and be able to handle difficult conversations not only with the patient and family, but with physicians who need to buy into the discharge plan,” Bankston says.

Bankston recommends that the complex case manager get involved with the patient as early as possible. “The referral could come on day one if it’s obvious the patient will need a lot of support, or the treatment team may uncover issues during the stay,” she says.

In some cases, the complex case manager might take over everything about the case. In others, the primary case manager may stay involved.

The complex case manager should collaborate with the multidisciplinary team and the family or caregivers, keeping everyone informed. Bankston recommends that the entire treatment team and family members meet to discuss the issues, the patient’s discharge needs, and the next steps.

“Cases can languish when there’s no communication between the family and the physician or ancillary staff, or when there are legal and other issues that have to be handled. The complex case manager can overcome this roadblock by calling all the parties together and presenting all the options for transitioning the patient,” she says.

Track the disposition of the cases the discharge planning specialist handles and determine how many days were saved by intervening. Then tabulate the cost savings to prove the value of the position going forward, Cesta says.