Social workers facilitate discharge process

Community resources can help prevent readmission

A visit from a Horizon/Mercy social worker often is the only visit that many of the health plan members get while they’re in the hospital.

"It’s tough having a disease that disables you and that you know you’ll have to deal with for the rest of your life. When these members have contact with someone who shows genuine concern for them, they really appreciate it," says Pamela Persichilli, RNC, the manager of clinical services, utilization management for the Trenton, NJ-based insurer.

The Horizon/Mercy social case management consultants work with the health plan’s publicly insured managed care members who are disabled with Social Security benefits.

They work with the hospital’s discharge planners to ensure that patients’ discharge needs will be met so they can be discharged on time.

For instance, if the member needs home oxygen, they set it up in advance.

But perhaps more importantly, the social case management consultants help the members avoid re-hospitalization by helping them learn to navigate the health care system and tap into community resources.

"When most people are discharged from the hospital with a plan of care, they call the doctor and make an appointment as directed. It never happens with this population," Bonaparte says.

The social case management consultant makes the call and sets up the appointment while the member is still in the hospital. She gives them a date and time and makes any transportation arrangements that are necessary.

The social case management consultants coordinate receiving medications from the pharmacy, ensuring that the prescription is filled in a timely manner so the members can take their medicine and prevent readmission, Bonaparte says.

Most of the members need some kind of durable medical equipment. The social case management consultants ensure that they have what they need.

The health plan provides some of the transportation and coordinates with local transportation agencies in the 21-county area to get members to and from their physician appointments.

The social case management consultants help meet the needs of the members by pointing them in the right directions and helping coordinate community services.

Some of the members live in homeless shelters or on the street.

Many have substance abuse and behavioral health problems.

While Horizon/Mercy is not responsible for the services, the case managers put the members in touch with agencies that can help them.

The case management social workers educate the members’ primary care physicians about community services so they can make referrals to drug and alcohol rehabilitation program.

For instance, the social case management consultant identified one member who was a frequent utilizer of the emergency department, sometimes visiting it several times in a single day. She got him linked to a behavioral health program, and the frequency of his emergency department visits dropped tremendously.

Sometimes it takes little more than a telephone call to help a member get help.

"Food and shelter are big issues with these members. By the time they pay the rent, they may not have enough money for food. The social workers put them in touch with food pantries in their local area," Bonaparte says.

In addition to their disabilities, many of the members have chronic illnesses, like diabetes and hypertension, which are exacerbated by poor nutrition.

At the same time, lack of food also affects their compliance. "When you are concerned about where your next meal is coming from, you’re not too concerned about taking your blood pressure pill. Hunger pains are a more pressing need," Bonaparte points out.

The social case management consultants work closely with community organizations. During the assessment, they ask the members if they have enough money to pay for rent or food. If the answer is no, they link them with an agency that can help.

"Some of these members would not have known about these services or would have been embarrassed to admit that they needed them. We ask the questions up front to break the ice," Bonaparte says.