CMSA Today - Issue 8, 2012 - (Page 6)

Transitions in Care Transitions in Care: Case Management for the 21st Century BY LAURA OSTROWSKY, RN, CCM, MUP C ase management is about “the right care in the right place at the right time.” It’s all about transitions. Effective transition planning includes ongoing assessment and the development of safe discharge plans. It is designed to maintain patients at the correct level of care by preventing readmissions, maximizing patient knowledge and empowering patients to perform self-care and make informed decisions. These assessments and plans need to be developed at all sites of care, not just when patients are hospitalized. The National Transitions of Care Coalition defines transitions in care as “the movement of patients from one setting to another including logistical arrangements, coordination among health professionals, and education of the patient and family.” (our ED), the main Outpatient Clinic, the Pediatric Day Hospital (PDH) and our Patient Care Advocacy Program. Cancer has become a long-term, even chronic condition for many patients. Inpatient Case Managers at Memorial are service-based, following their patients through treatment, maintaining ongoing relationships, and working with them each time they are admitted to the hospital. Discharge plans include the full array of in-home services from low to high tech and transfers to acute, LTAC, and subacute facilities. We incorporated telehealth services into our discharge plans for amyloid patients three years ago. Building on this success, we have implemented telehealth for patients with new onset atrial fibrillation. The Urgent Care Center (UCC) Case Manager works with staff, patients, and families setting up support services in the home including safety evaluations, infusion and wound care, as well as palliative and hospice care, successfully averting unnecessary admissions. When a patient does require admission, the UCC Case Manager completes an initial assessment and communicates findings to the Inpatient Case Manager who continues the planning process to prevent delays, coordinate services, shorten length of stay, and plan for the At Memorial Sloan-Kettering, a 470-bed cancer specialty hospital in New York City, we have used this model as a guide in the development of our program. Since 1998 the case management program has evolved and grown to meet the needs of our patient population. We began by consolidating utilization management and discharge planning functions for all inpatients. Effective transitions required CM presence at all points of access to care. To that end, the last decade has been a time of program growth beyond inpatient care to incorporate ambulatory care and advocacy for patients seeking access to our specialty care services. The program supports patients as they make the transition from one level of care or provider to the next as they move through the care continuum. We also provide education to hospital staff about case management and the transitions model to enhance collaboration and broaden awareness of our services. Transition specialists are case managers with expertise in insurance and managed care coverage, discharge planning options, and problem solving. They are patient advocates with the ability to think outside the box to create safe clinically complex discharge plans. Current services include not only inpatient case management, but also Urgent Care 6 CMSA TODAY next stage in our patients’ ongoing care. With the advent of observation care regulations and the need to differentiate observation services from admissions, the UCC CM reviews patient care and medical documentation and works with the medical staff to determine appropriate patient status. CM skills are integral to identify the correct level of care. To minimize time in observation units, CM assessment skills are employed to identify community supports for patients following discharge from observation status. Support services can be as simple as a single visit for a safety assessment or to reinforce teaching or multiple home care visits to provide ordered skilled services. Our Clinic Case Manager works with the office practice team to identify patients who can benefit from supportive services to keep them at home in the community. She serves as a consultant and educator for the clinical team and is an expert in insurance coverage issues and community resources; she applies this knowledge when rounding with staff and reviewing daily appointment lists to identify patients for intervention. Admissions are avoided with home physical therapy, infusion care, health teaching, and more. The Case Management department provides counseling to patients nearing end of life when curative treatment options are limited or nonexistent. We discuss realistic goals and identify options such as palliative care and hospice. Preparing patients at this stage allows them to exercise choice and optimize the quality – and sometimes even the quantity – of the time they have left. A recent letter from a family member thanked the case manager for her advice and counseling. The patient had spoken Issue 8 • 2012 • DIGITAL

Table of Contents for the Digital Edition of CMSA Today - Issue 8, 2012

President's Letter
Transitions in Care
Passion in Case Management
Patient Assistance Programs
Association news
View from Capital Hill
Case Management and the Law
Ethics Casebook
Mentoring Matters
CMSA Corporate Partners
Index of Advertisers

CMSA Today - Issue 8, 2012