By Melinda Young


Hospital case managers can use a collaborative case management tool to improve care coordination and patient satisfaction.

• The Cleveland Clinic South Pointe Hospital uses the tool to collect information about patients’ medical needs, social determinants of health, and cognitive status.

• Questions in the tool might include “What are your barriers to healthcare?” and “Do you visit a primary care provider?”

• Since using the tool, the hospital has scored 100% on patient satisfaction survey metrics related to information provided to patients and addressing patients’ needs at discharge.

A patient-centered, collaborative case management tool can help hospital case managers anticipate patients’ needs and ensure an appropriate discharge and transition of care.


Inadequate care coordination can lead to rehospitalizations and expensive care, says Carol Manuel, RN, BSN, CCM, inpatient RN care coordinator at Cleveland Clinic South Pointe Hospital.

“If we don’t coordinate care and get patients to the appropriate level of care, that results in avoidable healthcare costs and unnecessary readmissions,” Manuel says. “Often times, coordination of care is not handled appropriately, but proper care transitions will [prevent] some of the wasteful spending.”

The patient-centered case management tool can help ensure better care coordination by examining patients’ current needs, potential of delirium and dementia, and social determinants of health.

Case managers check patients’ potential barriers to maintaining their health in the community. These might include financial restraints, transportation needs, and any other information that might help them transition the patient to a safe and appropriate community placement, Manuel says.

The tool assists case managers and other healthcare professionals in understanding patients’ post-discharge needs. When these needs are poorly communicated and understood, patients are more likely to experience unnecessary hospital readmissions, she adds.

Also, the tool encourages making patients and their families a part of the discharge plan, giving them some control over it. “Patients need to have some control in order for it to be successful, and we want them to be compliant, so they will have some buy-in,” Manuel says.

Patient satisfaction survey scores have improved since the case management tool was implemented. The hospital scored 100% on metrics related to information provided to patients and addressing patients’ needs at discharge, she says.

The electronic tool includes checkboxes and drop-down box information. It includes these questions:

• What are your barriers to healthcare?

• Do you have a primary care provider?

• When was the last time you were in a hospital?

• Have you been in a skilled nursing facility within the last 30 days?

• What are your medications?

“The tool addresses medical and health literacy and patient needs prior to admission,” Manuel says.

When patients answer a question, the drop-down box allows the case manager to individualize the information by writing additional observations or patient answers.

The tool also asks for information about the patient’s prehospitalization mental status. “Was the patient oriented or disoriented? Are they confused?” Manuel says. “It will further drop down and signal to us to go to a delirium screen.”

The tool is comprehensive and allows case managers to note nuanced information, such as “The patient had been managing well alone at home, but has progressively gotten worse,” she adds.

As case managers learn to use the tool, they might bring it into the patient’s room with them. Soon, they know which questions to ask patients, take handwritten notes of patients’ answers, and then input those responses in the tool after they leave the patient’s room.

“I’ve been doing this for over seven years, and I know what questions to ask,” Manuel says. “I can go back to the tool at any time to update it as I learn new things or if something changes.”

Manuel takes notes by hand, then enters the information into the electronic tool after leaving patients’ rooms.

“We want people to complete the tool within 24 hours,” she says.

Case managers introduce themselves to patients and explain that discharge plans are started at admission. “We say, ‘We need your input. This is your plan, and we want it to be appropriate and safe,’” Manuel says. “I am sitting down with the patient, when I’m talking to them, and the family members might be there, too. It’s a conversation.”

For instance, the case manager will ask patients which home care agency or skilled nursing facility they prefer. If the patient has not yet been referred to a post-acute care setting, or has not chosen one, the case manager answers that question as “pending,” Manuel says.

Case managers also assess patients’ mental status, checking to see if patients are forgetful. “After gathering all the information, I say, ‘I know you are having difficulty remembering everything. If it’s OK with you, can I call your family member to get additional information?’” Manuel says.

The care coordination includes helping patients make follow-up appointments with primary care providers. Case managers also assist with medication reconciliation and linking patients to other post-acute care providers, as needed.

Part of their job is to ensure better communication between the hospital and all other providers, Manuel says. “We provide a summary of care to all community providers, including nursing homes, medical equipment sites, and home care providers,” she says. “There is a summary of care in our case management tool.”

When case managers work with primary care providers, that summary of care is sent to the patient’s other providers. If the providers, including home care agencies and skilled nursing facilities, are within the health system’s network, the information is sent electronically. For out-of-state providers, the information might be faxed. “The summary of care includes information about why the patient was hospitalized and what the patient was treated for,” Manuel says. At discharge, they give patients information about their care plan and medications, she adds.

Case managers help patients contact post-acute care providers, pharmacies, and home care providers. “We want them to be safe, and we want them to go home and stay home without having to come back to the hospital,” Manuel says.

The tool is popular among case managers because it has allowed them to individualize patient care coordination to a greater extent than before, she notes. For instance, the tool encourages case managers to look at delirium and dementia as separate conditions. Dementia is considered a chronic condition, while delirium might be acute, she explains.

“The tool helps us identify whether a patient has an acute issue, like delirium, which is treated differently,” Manuel says.

Home care agencies and other providers rely on the hospital’s care plan and medication discharge summary, she notes. “I used to be a home care nurse, and that information is crucial and essential,” she says. “Patients can have 40 to 50 bottles of medicine, and if we didn’t get a discharge form from the hospital, then we’d call them.”