By Melinda Young


Hospital case managers can engage in patient-centered care to improve care transitions and help patients meet their personal health and transition goals.

  • Case managers should advocate for the patient’s transition wishes.
  • It also is important to talk clearly with patients about safe discharge.
  • If it is not possible for a patient to transition to the facility he or she desires, case managers should explain this honestly, talking about safety and insurance issues.

Patient-centered care is a simple, evidence-based way to improve care transitions and patient outcomes. Hospital case managers can benefit from learning more shared decision-making tactics, a case management leader says.

“Patient-centered care is about putting patients at the center of their plan of care, while they’re in the hospital,” says Mary McLaughlin Davis, DNP, ACNS-BC, NEA-BC, CCM, senior director, care management nursing at Cleveland (OH) Clinic. “It’s not about telling the patient, ‘You need home care and you need to follow-up with this doctor.’ It’s about helping the patient, listening to the patient first, and then discussing what are the patient’s goals for this hospitalization and beyond.”

Hospital case managers need to look beyond the discharge and the patient’s post-acute care transitions. “The nurse case manager and/or social worker needs to look and think, ‘What does the patient need after that?’” Davis says. “There is so much more that needs to be taken into consideration.”

Case managers can ask:

  • Are patients part of the organization’s accountable care population?
  • Are they part of a narrow network or specific insurance group?
  • Are they insured?

“Just look at them as a whole, looking at what they were doing before they came into the hospital, what is their plan going forward after they leave the hospital, and how do we help them,” Davis says.

Everyone on the team, from nurses to therapists and case managers, should be in the same mode. Case managers pull everything together and help coordinate care and inform the team about patients’ wishes.

“The doctor might say, ‘I want the patient to do this, but the case manager needs to be an advocate for the patient,” Davis explains. “The case manager should say, ‘They really want to go home and don’t want to go to another facility, and what can we do as a team to help the patient go home?’”

Here are the steps case managers should take to improve patient-centered care:

• Conduct a thorough assessment. It starts with the case management assessment. Case managers should learn about the resources and support the patient might or might not have, Davis says.

An elderly patient may be frail and alone, but if the patient has access to savings, then perhaps he or she could afford to hire in-home help. Or, maybe the person holds a long-term care insurance policy.

“It’s up to us to ask those questions and problem-solve with the patient about what might be available to them,” Davis says. “Conversely, the patient might say, ‘My daughter will help me, and it’ll be great.’ But if you ask the right questions, you may find that the daughter lives in another state and calls every day, and that doesn’t cut it.”

• Discuss safe discharge with patients. It is important to talk with patients about what constitutes a safe discharge.

“Help patients understand what is realistic and what isn’t,” Davis says. “Sometimes, patients make bad decisions. This is their right. But we build in as much of a safety net as possible.”

If a patient does not prove the optimal transition path, it is up to case managers to help make a good handoff to community resources and medical resources so the patient’s decision is less likely to result in rehospitalization. Finding community resources during the COVID-19 pandemic has been especially challenging because many resources are more limited or no longer available, Davis says.

• Acknowledge limitations. Sometimes, it is not possible to meet the patient’s desired needs and provide the safest possible discharge. “Some patients want to go home, but it’s so unsafe, and that can cause real moral distress,” Davis explains.

This is when case managers should emphasize to patients they can safely return home if they first spend time in a skilled nursing facility. Or, if the patient still resists transitioning to a nursing home, the case manager can help the patient connect with home health services, Meals on Wheels, and other community-based support.

The sickest patients might ask to go home with just a family member’s care. If the case management team does not think this is adequate, they should plan to follow up regularly.

“We have sent patients home with medical equipment and a family member who insisted they could handle it,” Davis says. “We’ve all had our doubts about the very sick patient, and we’re thinking, ‘I don’t know how a young, 20-something son will take care of his 50-something mother with all of the things going on with her.’”

But the patient and family insist, so they follow the patient’s lead and put everything they can into place. “It really requires having vendors looking at the situation and helping to make decisions about what will work at home in terms of equipment and that kind of thing,” Davis explains. “It can be very complex.”

• Improve communication. “Usually, social workers are very skilled at having [tough] conversations with patients,” Davis says.

It might be up to the team to advocate for a transition that provides services, such as rehabilitation, that the payer turns down. “Often, the case is the family agrees to do acute rehab or have the patient go to a long-term acute care hospital, and the insurance company says, ‘No, they’re fine to go to a skilled nursing facility,’” Davis says. “But you always advocate for the patient, taking it as far as you can and also taking it to do the appeal, as quickly as possible.”

Case managers can ask the physician to schedule a peer-to-peer insurance-physician conversation to discuss making the change. If these efforts fail, the case manager should discuss this with the patient and family.

“Case managers need to understand all of the implications of transitions because they could go down a rabbit hole with the patient if they don’t understand medical necessity criteria, Medicare, and compliance rules,” Davis says.

For example, patients could use up all of their Medicare acute-care days and find their transition options are limited, so they cannot go to acute rehab or a long-term acute care facility, she says.

“It’s important for case managers to keep all of those elements in mind, because otherwise they are not really helping the patient or the team,” Davis says. “It’s incumbent on us to wear all of these hats, and that’s the level of expertise that would set us apart.”