Case managers and other healthcare providers increasingly are finding that their work includes collaboration and communication with providers and health advocates across the care continuum.

For health advocates, these interactions are necessary to help the patient achieve optimal health and function.

“As soon as any of our clients are hospitalized, the first call we make is to the case manager,” says Bobbi Kolonay, RN, BSN, MS, CCM, president of Holistic Aging & Options for Elder Care in Pittsburgh.

“We introduce ourselves and we say we want to make their job as easy as possible,” she says. “We provide them with all the information they need.”

For example, if health advocates have visited patients’ homes, they will tell case managers about patients’ home environment, including listing any caregivers who can help patients, Kolonay says.

“Once case managers develop a trusting relationship with us, we can make their job so much easier,” she adds. “We work with case managers and they let us know the results of tests. They’re the best people for us to work with.”

Health advocates also show case managers and other providers the patient’s signed HIPAA forms when they introduce themselves and briefly explain the services they provide to clients.

“If I’m called in to see a client in a hospital bed, it usually means the client was in the hospital for a long period of time — days or weeks,” says Jeanne Stanton, RN, BSN, MHA, care manager, LifeSpan Care Management of Haddonfield, NJ.

“Then, the hospital says the person needs to leave tomorrow and go to this long-term care or skilled nursing facility, and the family and client are upset that they have less than 24 hours to figure this out,” she adds.

That is when the health advocate is called in by a physician, attorney, or family member.

“They might call us to quickly resolve this issue,” Stanton says.

“I do a quick physical and psychosocial assessment to see if the level of care is correct, and I usually have two to four hours to figure this out.”

For instance, Stanton will send a family member out to look at two possible settings for the patient’s next transition.

“I might talk with physicians and say, ‘Why did you choose today for the discharge? Why didn’t you discuss this with the family earlier?’” Stanton says.

Sometimes, providers will postpone discharge for a day. The health coach might convince the assisted living facility or long-term care facility to allow the patient to stay for a week instead of the 30-day minimum stay.

“If they need to be moved out within four or 24 hours, then let’s talk behind the scenes and see what we can come up with to help this family,” Stanton says.