In today’s healthcare world, communicating with other clinicians in the hospital and in post-acute provider organizations is essential to ensure patients receive the care they need to stay out of the hospital and the ED.

“Patient-centered communication is huge,” says Teresa Marshall, RN, MS, CCM, senior managing consultant for Berkeley Research Group.

Case managers must communicate constantly with other departments and talk to their counterparts in post-acute provider organizations as well as their peers at other hospitals, adds Elizabeth Lamkin, MHA, chief executive officer and partner in PACE Healthcare Consulting, based in Bluffton, SC.

“The more everyone involved with a patient works together and shares information, the better it is for the patient,” she adds.

Case managers, treating physicians, and clinical documentation improvement staff comprise a three-legged stool, and interaction between them is essential, Lamkin says.

“The case management department and the clinical documentation improvement staff should become partners and ensure that documentation is correct in real time,” she says. “Work closely with the clinical documentation improvement staff and teach them inpatient criteria. Educate the clinical team about how patients flow into the system.”

Case managers also should be in constant communication with nursing and ancillary providers and should attend daily rounds on every patient with the entire multidisciplinary team, she says.

She recommends that case management departments have active physician advisors who can act as liaisons between case managers and physicians, Lamkin says. “Today’s healthcare environment makes it more important than ever to engage medical staff,” she says.

Population health initiatives and bundled payments are not going away, and case managers need to help their hospital succeed, Lamkin states.

“Continuity of care is still a big focus. Case managers need to understand how the continuum of care is structured, where the patients are coming from, the potential denials they could have, and how to manage care along the post-acute continuum,” she adds.

Hospitals should establish a process to improve transitions and communication with providers at the next level of care, Marshall says.

She suggests working with post-acute providers to develop a method to alert providers along the continuum when a patient is treated by a provider at a different level of care.

“There should be some type of trigger so that when case managers assess patients at admission, they will know that they are part of a population managed outside of the four walls of the hospital,” she says.

“Hospital administrators should ensure that case managers have the infrastructure so they can identify at-risk patients in the ambulatory and inpatient setting, and as they transition through the continuum,” Marshall adds.

She advises hospital-based case managers to work closely with their counterparts in other settings to ensure patients get what they need without duplication of effort.