Hospital case managers are part of a care team collaboration that spans healthcare settings and disciplines, focusing on improving patient care and preventing high-risk patients from being readmitted to the hospital.

“Some of the collaboration’s achievements have been related to reducing the frequency of these individual patient readmissions to the hospital over time,” says Colleen Royer, RN, MSN, CCM, senior director for care management at Cleveland Clinic Health Systems Eastern Region Hospitals.

“A few years ago, we noticed more and more similar patients returning to our hospital,” Royer says. “We didn’t have the ability to know if someone was at one hospital versus another hospital, and we were not sharing individual care plans.”

The hospital’s ED team and additional healthcare professionals began meeting to talk about individual cases and discover the root cause of why these patients returned repeatedly, she adds.

“The team developed comprehensive plans, individualized to the patients,” Royer says.

The next step was to identify the patients who most needed this targeted intervention. The solution involved metrics collected electronically. Data included claims data, lab values, multiple readmissions, frequent ED use, and two or more chronic diseases, she says.

The technological tool assigned each patient a score. A high score was considered high risk, and this patient could be included in the intervention, she adds.

The individual plan of care team consisted of ED physicians, case managers, a case management manager, social workers, ED nursing teams, and specialists including psychiatrists. Community providers, including primary care physicians, community case managers, and community mental health workers, also were included as team members.

“There is even pastoral care,” Royer says.

The plan of care is written from an electronic template that one team member documents. The whole team contributes to the plan, addressing the primary reasons why the patient keeps returning to the hospital. The plans address the patient’s chief issues, goals, and interventions, she adds.

The team follows patients over time and reassesses plans, as needed.

In one case, a patient had 37 hospital encounters over a one-year period — including eight encounters in the month before the plan was created. After the team implemented the plan of care, the woman’s readmissions dropped to four for the remaining four months of the year, with no readmissions in 2019.

Success follows when the team coordinates its efforts. The team discovers and assesses patient barriers to better health, including transportation issues. If the patient is experiencing food insecurity, the team might connect the patient to food pantries. If the patient needs a wheelchair and insurance will not cover the expense, the team finds a funding solution, Royer says.

“We become creative when seeing what’s available for patients in the community,” she adds. “Maybe a church has a resource that we’re not aware of, so we put all of our heads together to see what is available.”