Professional case management doesn’t always happen
True story demonstrates gaps in transitions
When Marcia Diane Ward’s mother was treated in the emergency department, admitted to a nursing unit, and then transferred to a skilled nursing facility, Ward, RN, CCM, PMP, a case management consultant based in Columbus, OH, was chagrined to observe that the coordination between levels of care wasn’t any smoother than it was when she first became a case manager.
"Getting back into the clinical environment gave me a memory trip. I remember that back in 1993, I wrote about the lack of transitions as patients move between levels of care and what we need to do as a profession to correct the problem. I’ve been in the healthcare business a long time, and I still see little progress when patients are handed off from one facility or level of care to another," she says.
Ward agreed to tell her personal experience in hopes that it will be a wake-up call for case managers overseeing patients through the network of healthcare management and delivery.
"I saw gaps in care throughout the continuum. Case managers are supposed to be advocates for patients, but that doesn’t always happen today, in part because they are overwhelmed by often working 12-hour shifts, are assigned tasks that are not part of the Case Management Standards of Practice, and are inundated with paperwork and continuous data entry," she says.
When case managers try to do utilization review, discharge planning, care coordination, and transition planning along with copying, faxing, and other clerical tasks, they can’t get it all done and things fall through the cracks, adds BK Kizziar, RNC, CCM, CLCP, a case management consultant based in Southlake, TX.
"The case management role is first and foremost being an advocate for patients, but often that’s not the path we are directed to take," she adds.
When her mother was hospitalized, Ward felt fortunate that she had the skills to make sure her mother got the care she needed and ensure that all providers were aware of her medical history. "But not everybody has healthcare experience, and it’s very consequential for patients and their families when clinicians don’t talk to each other and don’t look at the whole picture," she says.
Ward tells of consistently reminding clinicians of basic needs of her mother’s that were not being . "The healthcare industry needs to address the holistic treatment needs of the individual," she says.
Medical specialists tend to concentrate on one aspect of the patient’s condition, Ward says. "If you are admitted to the hospital by a physician who is concentrating only on his or her specialty, your care may be jeopardized unless there is a case manager who recognizes it." She recommends that as patient advocates, case managers make sure the patient’s other problems, such as incontinence or refusal to eat, are addressed. Otherwise, the problems may never be treated.
"My mother was hospitalized with heart problems and for insertion of a pacemaker and saw a specialist referred by her cardiologist. But nobody was treating her pulmonary edema until I pointed it out and asked for a pulmonary consultation," she says.
Ward addressed her mother’s gaps in care with the nursing manager on the floor and asked for a generalist to assess the problems not being treated by the cardiologist. "If the cardiologist as the primary admitting physician can’t prescribe a stool softener or a sedative, a generalist must be called in as an adjunct to the specialist," she says.
Ward reports giving the list of her mother’s medication to the nursing staff and discovering that there was an information gap between nursing and the pharmacy. "Every day, I had to review the medication she was taking and point out that some of her regular medication was missing. In my mother’s situation, the hospital’s case management process was a weak link. As a nurse, I was very aggressive in advocating for my mother’s care. Most families wouldn’t be able to do that," she says.
The skilled nursing facility where Ward’s mother was transferred had an employee who was called a case manager, but he stayed in the office all day. "His role seemed directed toward administrative functions," she says.
When Ward’s mother was transferred to the skilled nursing facility, the discharge notes didn’t come with her. "I had to run those down and the skilled nursing facility asked me to drive to the cardiologist’s office and pick them up. There was no information on the pacemaker, so I called the cardiac laboratory at the hospital to get details. It turns out that the physician thought the discharge planner would take care of it and vice versa," she says.
Case managers bear a sizeable responsibility to ensure that patients are safe in the next place they go, whether it’s back home, to an assisted living center, or to a skilled nursing facility, and to make sure that the hand-off to the next level of care goes smoothly, adds Catherine M. Mullahy, RN, BS, CRRN, CCM, president and founder of Mullahy and Associates, a Huntington, NY, case management consulting firm.
"Case managers should never treat the hand-off like a hot potato. They should continue to be accountable for what they did to get patients ready for the transition and to make sure that providers at the next level of care have all the information they need," she says. "Case managers need to continue to assert themselves in their patients’ care and continue to position the value of case management for achieving the optimum outcome for their patients," she adds.
Based on her experiences, Ward believes that a case manager should be assigned to every patient in every setting and should make daily rounds. Case managers should never be afraid to step up and ask physicians about discharge orders or make sure the pharmacist is overseeing the medications, she says. "Case managers can ask the right questions and immediately pull all the disparate pieces together. They are the safety net within the healthcare delivery system that coordinates all the pieces and that make sure nothing falls between the cracks in the continuum of care," Ward says. n