Care transitions can be challenging whether they involve patients transitioning across the street or across the country. It is the job of case managers or transitional care coordinators to make the process work smoothly for patients.

• Electronic medical records can help with communication during the care transition process.

• Working with social workers, transitional care coordinators focus on care continuum and quality.

• The transitional care process also helps out-of-town patients find home care agencies, skilled nursing facilities, or other healthcare services in their hometowns.

Some of the biggest challenges in care transition involve bridging patient care between the hospital and the community — especially when the community is hundreds of miles away.

Communication always is the key, says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director of care management for the Cleveland Clinic Health System. Davis also is the immediate past president of the Case Management Society of America in Little Rock, AR.

Electronic medical records can help transitions — even across the miles. But these only work if the two healthcare organizations use compatible electronic systems.

“One of our other major hospitals is a county hospital that uses [the same system], and if our patients go back and forth, we can see what’s going on with them and communicate with their care coordinators,” Davis says. “We always communicate. If they go to another hospital, we will call that care coordinator.”

With an electronic referral system, the health system can refer patients to skilled nursing facilities and home care easily. “But we also encourage people to pick up the phone, especially for complex patients,” Davis says.

Cleveland Clinic is on the frontier of another transition in case management and health systems, says Stefani Daniels, MSNA, ACM, CMAC, president and managing partner of Phoenix Medical Management of Pompano Beach, FL.

The health system changed its case managers into transitional care coordinators, and they work with social workers to ensure patients receive optimal care coordination throughout their hospital stay and beyond.

This newer model is something that hospitals increasingly will need to implement. They will have to redefine case managers’ roles to focus on care transition and coordination, separating out the utilization management role. Instead of focusing primarily on length of stay, they are looking more at care continuum and quality, Daniels explains.

“There still are hospitals I visit where length of stay is be-all, end-all, and that’s what case managers have to do,” Daniels says. “But it’s not by coincidence that the fee for value-based purchasing that Medicare put in place has as its indicator for efficiency Medicare spending-per-beneficiary and not length of stay.”

Spending-per-beneficiary is a key that ties together case management in the hospital and in the community. With the goal of lowering overall healthcare spending, case managers work collaboratively with patients and community case managers as they move between healthcare settings. For those within the same organization, the transition could be a face-to-face handoff, Daniels says.

For example, Daniels describes a health system that has four small critical care hospitals that feed into one flagship hospital. Care coordination activities include formal, structured handoffs so information from flagship case managers would be shared with satellite case managers, she says.

In a small hospital, case managers can do it all, Daniels notes. “One person may follow that patient through inpatient care and spend time in the community, visiting the patient at home or at a nursing home, or meet with home care staff, making sure everyone agrees on the treatment plan.”

Cleveland Clinic’s case managers, called transitional care coordinators, have departmental roles in the hospital, but they work with community managers at handoffs, Davis says.

This can be challenging. For example, one recent patient had several challenges, including being undocumented, unable to speak English, and uninsured. The patient also suffered a neurological problem that suggested a transition to a freestanding acute care rehabilitation hospital, she recalls.

“But that hospital was nervous because in acute rehab, you have to have a good home plan, and there are rules around that, too,” Davis says.

Acute rehab was the best option for the patient, so the hospital agreed to take the patient. “What happened was the patient ended up in another one of our hospitals, and the first hospital that originally received the patient was called and was in communication with the others,” she says. “They called the care manager at the second acute care hospital, saying, ‘This is what’s going on. Here’s a story of family, and this is what they need; this is what we’re recommending.’”

Communication during transitions is the right way to handle such patients, she says.

“It’s not just ‘close your eyes and hope for the best,’” Davis says. “We show concern for the patient and show concern for colleagues because we’re all in this together.”

When transitional care coordinators work with patients whose homes are miles and states away, they help the patients find community resources in their hometowns.

“We use a software system and do a search and see facilities, CMS ratings, and five-star ratings for facilities in their area,” Davis says. “We give the list to the family.”

When out-of-town patients have a primary care provider at home, care coordinators and social workers will reach out to that doctor’s office or to the home care agency that will be caring for the patient. If they do not have a primary care provider, the care coordinators work hard to find one, she says.

“Getting them set up with an appointment prior to leaving the hospital is a lot of work,” Davis says. “Everyone is committed to it.”

For instance, social workers research patients’ communities, often calling their local hospitals to ask them for referral contact information, she says.

“For some patients, home care services are not enough. Some have behavioral health components and need a behavioral health nurse,” Davis says. “Or if there is a diabetic patient with amputation and schizophrenia, the goal is to find home care that will integrate the behavioral health elements with him.”

Cleveland Clinic also has an ambulatory care management piece in which social workers take care of patients’ social work needs via phone. “We saw a need for that,” Davis says. “They’re tied to primary care practices locally.”

Sometimes the transitional care coordinator’s work depends on the insurance company and the insurer’s care manager.

“We connect with the payer’s care manager and ask who they recommend and how we can help this patient,” Davis says. “If there’s workers’ compensation involved, we definitely work with those case managers.”

Each case is different, with its own set of challenges. One patient might be difficult to transition from the hospital because of lack of insurance and other barriers. When this happens, the transitional care coordinator will need to set up a care conference to discuss the patient’s struggles and how using the hospital for this person’s care is not the most appropriate way to handle the case, she adds.

“As a group, across our system, we discuss it and really think outside the box,” Davis says. “We even have a global care conference for patients in our system when we are stymied and don’t know what else we can do for them to get them into a more appropriate level of care.”

The group discusses the case, thinking outside the box and using all internal and external expertise, she says.

“If any of us have a concern, we can always pick up the phone,” she says.