ICU to home care transition requires communication

Patients often go home sicker with complex needs

When patients with critical illnesses who require complex interventions are transferred from the ICU to home care, early assessment and consistent communication between nurse managers and case managers can help ensure that the patient and caregivers are truly ready for the transition.

"The nurse manager often will be the first to identify a patient that’s appropriate for case management," says Kathleen Moreo, RN, Cm, BSN, BPSHSA, CCM, CDMS, CEAC, president of the Case Management Society of America. "They can play a big role in the internal referral process."

With the increased role of managed care, patients often have less time in the hospital and in step-down units that allow for a longer transition to home. Patients also are increasingly going home with ventilators and other complicated equipment.

The role of the case manager, Moreo says, is to ensure that when patients and family leave the hospital, they are ready to take on their role in the patients’ recovery. To accomplish that, case managers work with a variety of sources, including ICU nursing staff, home health staff, and case managers for insurance companies.

Anne Llewellyn, RN, C, BPH, SHA, CCM, CRRN, CEAC, is a partner with Moreo in Profes-sional Resources in Management Education Inc. in Fort Lauderdale, FL. She also works in critical care at Imperial Point Medical Center, also in Fort Lauderdale.

With experience in case management and respiratory intensive care, she sees both sides of the case management/ICU nursing relationship.

"When you work with critical care patients, you have everything at your fingertips," Llewellyn says. "To be able to discharge a patient — especially one who’s medically complex — to home, you have to be able to make that transition and make sure that’s safe. Sometimes, we don’t understand all the issues that go into that."

Communication starts on intake

Llewellyn and Moreo say nursing administration should begin looking at patients as soon as they enter the unit with an eye toward what will happen when they leave. They say it’s never too early to start speaking with case management when it appears that a patient might end up needing home care upon discharge from the hospital.

"I think the biggest thing is being proactive," Llewellyn says. "When you know a medically complex patient has been admitted — maybe the patient is a new stroke, maybe they’re going to remain on a ventilator, they have COPD [chronic obstructive pulmonary disease] — you need to start planning."

Not only can an early start help smooth the transition to home care, it can give case managers the time to make the case to a payer that the patient needs step-down care before going home.

Being alert to subtle signs

Pat Orchard, RN CCM, CHE, assistant vice president for case management services for Virtual Health System in Voorhees, NJ, takes it a step further. She says every patient should be assessed for possible case management needs upon admission. That doesn’t mean, however, that every ICU patient will require case management. "It depends on what the needs are, and a person’s physical needs may be very different from their psychosocial needs," Orchard says.

As an example, she points to a young person admitted to the ICU after surgery who rebounds quickly and can start making decisions regarding his own care as someone who may not need case management. On the other hand, a patient with a lot of comorbidities, a complex illness, perhaps elderly with social issues, may need case management more. A likely candidate for case management might be a patient with congestive heart failure who is also diabetic, resulting in poor circulation and poor eyesight, Orchard says.

Orchard says that as care progresses in the ICU, nurses can give case managers important information about the coping skills of the patient and the family members who eventually will care for him.

"They see the family dynamics, they see the patient dynamics, they see things that might draw attention to possible discharge needs," she says. "They may see it on the very first day."

Important signals might be the way families deal with physicians, nurses, and others in the unit. Do they argue over unexpected things? Are they highly emotional?

"All the coping mechanisms of the family are very important," Orchard says. "It may seem inconsequential to the ICU nurse who is handling the issues at the time, but it also gives you a hint as to how the family is going to cope on down the line in transitioning the patient through the system."

Making the rounds

Ideally, this communication with case management should be a daily routine through a mechanism — such as mini-case conferences and mini-rounds — consisting of the case managers and the nursing staff. It’s also important to hear about what goes on over the weekend, Orchard says.

Although case managers tend to take the lead in patient and caregiver education, ICU nursing staff also play an important role, particularly in teaching the family to perform specific skills.

Nurses can also start early educating family members about what is expected of them, Llewellyn says. Many families know, for example, that home health nurses, therapists, and other professionals will be visiting the house, but don’t realize the family probably won’t have help around the clock.

One important job of the case manager is to follow up with the patient after he or she has settled in at home, to see if there are any problems or complications.

That information can be useful for nursing administration, as well, Moreo says.

"We need to find opportunities to come together to review retrospectively what has occurred, or concurrently what is going on," she says. "It’s a staff education process. If this happened with Client A and Client C comes in with some of the same comorbid issues, you may be able to tell the staff, Watch for this issue because this could be coming up.’

"As part of the case manager’s follow-up phone call when they document that data, wouldn’t it be appropriate for them to copy that information to the nurse manager on the outcome that they found after the patient went home?"

Moreo also suggests that case managers be invited to regular inservicing in the ICU, so that they’re up to date on issues that might present themselves with patients.

It’s all part of communicating among departments to help smooth the way for patients, she says. "In hospitals, what we do not do well is interface well from department to department. We interface about the things we have to — the JCAHO requirements, some staffing issues — but we’re not too good at advocating department to department on behalf of patients."

[Editor’s note: To contact Moreo or Llewellyn at Professional Resources in Management Education Inc., call (954) 436-6300; or e-mail Katmoreo@aol. com or]