Look beyond the discharge and plan patient transitions

Post-acute partnerships are becoming essential

As penalties rise for readmissions, it is critical for hospitals to implement and support continuity of care initiatives as patients transition from one level of care to another, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA), based in Little Rock, AR. "As patients move from the hospital to the skilled nursing facility to home, the role of the case manager becomes extremely important," she says.

Case managers should be doing care transitions, not discharge planning or patient hand-offs, she says. "It’s not just a matter of using different terms. It is a seismic shift in how we think," says Patrice Sminkey, RN, chief executive officer for the Commission for Case Management Certification, based in Mount Laurel, NY.

"We need to reset the conversation about where case managers are in the continuum. It’s not about discharge planning and getting patients out the door. It’s about looking at a patient from the point of entry and creating a plan that looks past the hospital and on to the next setting," Sminkey says.

"The time has come for partnerships to improve transitions. Hospital case managers can’t do it alone," says Karen Zander, RN, MS, CMAC, FAAN, president and co-owner of the Center for Case Management. She suggests developing a cross-continuum team of case managers and social workers who are focused on specific populations of patients.

The ideal situation would be for the same case manager to coordinate care for patients from admission through the hospital stay and for at least 30 days after discharge, Zander says. "If we want to keep patients from being readmitted within 30 days, the new mindset has to be a deep understanding of each patient’s disease or condition and its trajectory over time. It will be imperative for acute care social workers and RN case managers to understand the implications of what brought the patient to the hospital and what needs to happen after discharge — not only level of care but the medications, sequencing of therapy and specialist physician visits, educational goals that are realistic for each patient, community services, and mostly, the support from families and others."

Reducing readmissions is only the tip of the iceberg as far as new expectations for case managers and social workers, she adds.

Case managers need to sit down and get to know their patients in order to create a successful discharge plan, says Catherine M. Mullahy, RN, BSN, CCRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY-based case management consulting firm. They have to be able to identify the patients at risk and do something to eliminate the risk, she adds.

"In a lot of hospitals, case managers are doing bits and pieces of the case management process. They’re identifying patients at risk and getting them out of the hospital but they aren’t doing anything beyond that," Mullahy says.

Case managers need to identify someone at the next level of care who can understand and manage the patient and communicate with them about that patient’s condition and situation, she adds.

"The new way of thinking is that the discharge from a hospital is not a final discharge but a transition to home or a post-acute provider. The mindset has to change from concentrating on getting patients out the door as quickly and safely as possible to planning the transition. Case managers have to assess the patients well and evaluate their relative risks of being readmitted. We are all on a huge learning curve about that challenge," Zander says.