Reach out to patients beyond the hospital stay

Find out what led to admission

The Centers for Medicare & Medicaid Services’ (CMS) new emphasis on discharge planning makes it imperative for case managers to start discharge planning on Day 1 and create a discharge plan that takes into account what happened to patients before admission, says Jackie Birmingham, RN, BSN, MS, CMAC, a nurse educator based in Suffield, CT.

Case managers also need to look beyond admissions and discharges to what happens to patients across the continuum, she adds.

“Case managers are more essential than ever before for hospitals to succeed, but they no longer can just create a discharge plan, send patients out, and forget about them. In today’s healthcare environment, case management departments need to have a focused commitment to do outreach after discharge,” she says. All case managers want patients to be safe when they to go to the next episode of care, and Medicare is saying that the discharge plan is a patient safety issue, she adds.

The full story

Case managers need to know the full patient story—where patients are admitted from, their pre-admission functional status, their care coordination needs, and their discharge needs, not just what happened during the acute care episode, Birmingham says. Look beyond the admission for this hospital episode and determine what was happening in their lives that led to the admission or the readmission, she adds.

The pilot survey sheets ask a specific and separate set of questions about patients admitted from home and those admitted from a skilled nursing facility, Birmingham points out.

“Most of the time, case managers assess patients on admission to make sure they meet medical necessity criteria and to determine their care coordination needs. CMS wants case managers to assess patients who are admitted from skilled nursing facilities to determine what services they will need after discharge, if they should go back to a skilled facility, and if so, should they go to the same one,” she says. Many times, patient records list only a street address and case managers don’t know that patients came from a nursing home or other facility unless they ask, Birmingham says.

“Hospitals are already collecting data on the discharge disposition of patients but CMS now is looking at quality issues. Not only should case managers know that they send patients to certain facilities, they need to know what happened when the patient got there,” she says.

Case management departments should analyze their discharge planning metrics and evaluate patient safety and their post-acute network of providers, Birmingham says. Having a good network of post-acute providers is a patient safety issue, she says.

Post-acute providers need to have at least basic information about the patients who are referred to them, adds Elizabeth Hogue, Esq., a Washington, DC, attorney specializing in healthcare issues.

“I’ve heard a lot of complaints from post-acute providers that the information they receive from the transferring hospital is incomplete or inaccurate. This is a recipe for a readmission,” she says.

Discharge planners should provide a list of agencies or facilities that can provide the specialty care a patient needs, then let the patient and family choose, Hogue says. “In addition to being part of the Conditions of Participation, this also is part of the national standards of care for case managers,” she says.

A lot of times, discharge planning is a last-minute activity instead of starting on admission, Hogue says. A case in point occurred when her elderly mother, who lived at home alone, was hospitalized, she recalls. “I knew my mother would need 24-hour private care in addition to home health when she got home and I got the process started. If the case manager had waited until the day of discharge to start planning, it would have been difficult to get the services lined up, [and] she might have ended up back in the hospital or emergency department,” she says.

Outpatient navigators

Case managers need to evaluate outpatients as well as inpatients for their discharge needs, says Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, president of Patient Safety Education and Consulting in Dublin, OH.

“Discharge planners and social workers must function like outpatient navigators and make sure that once patients are discharged, they have everything they need to have a safe and effective discharge,” she says. For instance, if patients do not have transportation for their follow-up primary care visit, connect them with a service. Patients who lose a lot of weight are at risk for rehospitalization and may need Meals on Wheels. The discharge planner should make sure there is a process in place to ensure that the physician has pertinent information about the hospital stay before the patient’s follow up visit, she says.

For a long time, case managers have been under tremendous pressure from hospital administrations to move patients to the next level of care and shorten the lengths of stay, Hogue points out. “Now hospital administrators are going to have to realize that there is more to this game. They are going to be penalized financially if they don’t encourage discharge planners to create an effective plan to prevent readmissions,” she says.

Case management directors need to open a dialogue with the administration about the role of case managers and what the Conditions of Participation require them to do, she says.

Educate your administration to understand that discharge planning has an impact on patient safety as well as hospital revenue, Birmingham says.

Case management directors can use the new emphasis on discharge planning to clarify expectations of case managers and may be in a position to justify new staff, Birmingham says. “What case managers are asked to do is already overwhelming, and hospitals keep adding other functions,” she says.

For information about changes in the Conditions of Participation, visit the CMS Survey and Certification website (

For a direct link to the pilot project worksheets, visit:


• Jackie Birmingham, RN, BSN, MS, CMAC, Nurse Educator, Suffield, CT. e-mail:

• Sue Dill Calloway, RN, MSN, JD, CPHRM, CCM, CCP, President Patient Safety Education and Consulting, Dublin, OH. e-mail:

• Elizabeth Hogue, Esq., Healthcare Attorney, Washington, DC. e-mail: