Extend the discharge plan beyond hospital walls

Make sure patient needs are met at home

Instead of thinking of case management as a hospital model, start thinking about case management as a continuum model, which transcends where people receive care, advises Toni Cesta, RN, PhD, FAAN, senior vice president, operational efficiency and capacity management at Lutheran Medical Center in Brooklyn, NY, and partner and consultant in Dallas-based Case Management Concepts.

Look beyond the hospital walls to ensure that patients receive the services they need in the community to stay out of the hospital, she adds. "Hospitals can do a great job of discharge planning, but when the patient gets into the community, breakdowns can occur if they aren't connected to services in the community."

When patients are at greatest risk for readmissions or a return to the emergency department, hospitals should try to pass the baton to a community case manager, usually a nurse who works for the health system and is embedded in a clinic or physician office, Cesta says.

"Even if patients get home care services, when those are complete, they have no one to help them navigate. At-risk patients need to have a long-term relationship with someone who can make sure the care they need doesn't fall through the cracks," she says.

Case managers should stress the importance of keeping doctor's appointments and go the extra mile to make sure that patients have a follow-up visit with a primary care physician or specialist shortly after discharge, says Carol Levine, director of the Families and Health Care Project for the United Hospital Fund, a non-profit health services research organization based in New York City.

Make sure that the physician's office understands that patients need to be seen quickly. Sometimes a representative of the hospital can have more of an impact on getting an early appointment than a patient or family member can, she adds.

Lutheran Medical Center has partnered with its clinics to hold open slots every week for patients being discharged from the hospital, Cesta says. "Otherwise, it might take a couple of months for them to get an appointment," she says. The case management department clerical staff makes appointments at private physician offices, alerting the staff that the patient is being discharged and needs to be seen within seven days.

As lengths of stay decrease and the flurry of forms that payers mandate be given to patients increases, patients are often overwhelmed with a lot of information in a short time, points out Linda Sallee, MS, RN, CMAC, ACM, IQCI, director for Huron Consulting, headquartered in Chicago. It helps if case managers focus on the most important things patients need to remember and create a printed form with the information. Include the name and phone number of the home health agency and/or other post-acute providers, the name and phone number of their primary care provider, and the date of the next doctor's appointment, Sallee recommends. Give patients an alternative to coming back to the hospital. Educate them to see the doctor if they aren't feeling well as opposed to waiting until their condition deteriorates.

When patients are readmitted, make sure somebody goes to the home after the discharge and completes an assessment, checking on the patient's medication, food supply, and whether they have what they need to manage their condition at home. "So many times, patients go back to what they were doing before. It's a vicious cycle, and the only way to stop it is to find out what is going on in the home," Sallee says.

Each hospital needs to determine the diagnoses that are frequently readmitted in their particular area, Sallee says. Look at resources in the community that can help patients manage their condition after discharge and stay out of the hospital and emergency department.

Make sure patients have transportation to see their doctor or go to the drugstore to fill their prescription. If you're in a rural area or the patient is a shut-in, consider using telemedicine to monitor the patient's progress, she says. If they have psychosocial needs, or need help with meals or paying for medication, refer them to a program in the community that can help.

A lot of hospitals have begun calling patients at home after discharge, but it's not always useful, Levine points out. When patients and family members are inundated with phone calls from nursing, physical therapy, case management, and insurance companies, it gets annoying.

"Patients don't see the point of the calls and feel it's an intrusion. There are too many people making the calls and nobody is really listening. It's important to follow up, but hospitals need to find a way to elicit useful information and not just check items off a list," she says. She advises hospital to think out who is making the follow-up calls, when and why, and what happens to the information.

Sallee suggests telling patients they're going to get a follow-up call from the hospital and explaining the reason. "If you prepare them up front for what the calls are going to cover, and the person making the call has access to the discharge plan and asks about it, you'll get a better response," she says.