EXECUTIVE SUMMARY
Lack of communication prevents clinicians from delivering coordinated care, which often results in adverse effects on the patient and the hospital’s bottom line.
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Healthcare providers need to move from a fragmented system to an integrated one where entities across the continuum communicate and work together to improve patient care.
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Case managers should develop strong working relationships with post-acute providers, case managers at community organizations, and their counterparts at health plans.
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Multidisciplinary rounds are essential for breaking down organizational silos and ensuring that all clinicians are on the same page.
When hospital staff start examining the reasons patients are being readmitted, the famous line from the movie Cool Hand Luke may come to mind: “What we’ve got here is failure to communicate.”
Many readmissions occur because some vital piece of information falls through the cracks when patients transition between levels of care. In other scenarios, patients may come back to the hospital because they didn’t understand the discharge instructions or the importance of following them, their living situation or financial issues made it difficult to follow the their treatment plans, they were unhappy with their post-acute facility, or because they couldn’t afford their medication or needed post-acute services that were not covered by insurance.
In many of these cases, the readmissions could have been avoided if the hospital clinicians had better communications with each other, with their peers at post-acute providers, with healthcare payers, and with the patients and families themselves, the experts say.
“When clinicians operate in silos with little communication, it prevents them from delivering the coordinated care needed to meet quality standards and financial aspects. It’s important to build relationships with the staff inside the hospital and with post-acute providers,” says Jean Maslan, BSN, MHA, CCM, ACM, managing consultant for Berkeley Research Group, with headquarters in Emeryville, CA.
The new systems of reimbursement, such as Value-Based Purchasing, bundled payments, and other initiatives are changing the way care is provided for patients and make it imperative for clinicians in the hospital setting to communicate and collaborate with their peers across the continuum, says Patricia Hines, PhD, RN, managing director for Novia Strategies, a national healthcare consulting firm.
“Insurers are rapidly following CMS and adopting their own value-based payment initiatives. Hospitals are going to have to rethink how they approach the delivery of care and what skills are needed for success,” she says.
One of the big changes case managers must make is to shift their thinking from focusing solely on individual cases and what happens in each department of the hospital and start thinking about how every part of the entire continuum works on behalf of the patient, Hines adds.
Hospitals have taken the first step toward providing care across the continuum as they participate in accountable care organizations and bundled payment agreements, which mandate communication between providers, says Brian Pisarsky, RN, MHA, ACM, associate director at Berkeley Research Group.
“Many hospitals have started to develop relationships with local skilled nursing facilities and home health agencies, but few have built a comprehensive program that truly looks at patients along the entire continuum of care,” he says.
The problem hospitals face with all of CMS’ quality initiatives is that the current healthcare infrastructure was built for volume and not value, Pisarsky points out.
“We have to make a fundamental change in the day-to-day work of case managers. It’s no longer just utilization review and discharge planning. It takes a different approach from what we’ve done in the past and it means good communication with every provider throughout the continuum who comes in contact with the patient,” he says.
Hospitals need to make operational changes to ensure that patients overcome the clinical barriers to a safe discharge, Hines says. “Today’s healthcare system may not allow hospitals and other providers to do well in the future without making major changes in the way they work within their systems and across the continuum of care. Our fragmented healthcare system has to move to a more integrated model in which all members of the healthcare team collaborate on behalf of the patients,” she says.
Instead of limiting your communication with other team members to text messages and emails, get the entire team together every day and talk about each patient on the unit, Maslan advises.
“Multidisciplinary rounds are so important because they involve person-to-person direct communication. The process builds a team on the unit because everybody is getting together and talking about goals and advocating for the patient. Too much is lost when we rely on technology for communication,” she says. (For tips on conducting multidisciplinary rounds, see related article on page 4.)
Communication with patients and family members is also extremely important, not just during the initial assessment but throughout the stay, says Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management.
Case managers need to take the time to find out about the patient’s living situation, support in the community, healthcare literacy, financial issues, and other details in order to develop a workable discharge plan, she adds.
In addition, case managers need to ensure that patients and families understand the patient’s condition and prognosis as well as their responsibilities after discharge.
“Patients are so sick when they are discharged that often the family doesn’t understand what is happening. One reason patients are being readmitted is that they get home and don’t know how to take care of themselves, or the family doesn’t realize the extent of the care they have to provide. It behooves us as case managers to make sure patients and families get the information and education they need before discharge,” she says.
Rossi recommends individual team and family case conferences for patients with complex needs. “The team needs to meet first to develop strategies and then schedule a meeting with the patient and family,” she says.
Everyone who comes in contact with the patient should talk about the estimated date of discharge and plan of care, rather than discussing it the day the patient is scheduled to be discharged, Maslan says.
In addition to providing extensive patient and family education, hospital case managers need to have good communication with case managers at the home health agency and the health plan who can take over the care coordination, Rossi adds.
“Bundled payments and accountable care organizations make it necessary for hospitals and post-acute providers to communicate and that’s a good thing for patients,” Maslan says.
Focus on the big picture and develop relationships with all providers in the community who treat patients after discharge, she adds. These include case managers at physician offices, community case managers such as those at the Area Agency on Aging, skilled nursing facilities, and home health agencies, she says.
“It’s important to have that connection between the inpatient case manager and the community case manager who may be going into the patient home or working with the patient at the physician office. That way, they know what is going on with the patient and can give the patients the same message they received in the hospital,” Maslan says. (For more information on building relationships with post-acute providers, see the December 2015 issue of Hospital Case Management.)
Hospital case managers should communicate with their counterparts at the patient’s payer organization, Rossi says. “So often the hospital and health plan don’t communicate except when there is the potential for a denial. But if a high-risk patient is going home, the hospital case manager should alert the case manager at the health plan about providing post-discharge care,” she says.
“Once patients leave the hospital, hospital case managers lose touch with them. But if they collaborate with the health plan case manager about post-discharge services, patients will benefit,” she says.
Some hospitals have developed joint operations committees to meet quarterly with representatives from key health plans, Rossi points out. “This opens up communication and helps the hospital and health plan work collegially to improve patient care, and not just in an adversarial manner when the health plan make a denial,” she adds.
Technology has made it easier to communicate but it can’t replace face-to-face communication, Maslan adds. She advises case managers to spend less time in the electronic medical record and more time talking face to face with their patients and the treatment team.
“It may take case managers 20 minutes to find out about a patient by reading a chart, but they can walk into a room and know what is going on in 30 seconds,” she says.
As they document, clinicians need to get in the habit of painting a clear picture of the patients, their conditions, their needs, and the plan of care so that whoever is on the treatment team can see what the issues are, Rossi says.
“When the communication is by email or texting, the whole team doesn’t get to see what the issues are. It doesn’t take that much time to succinctly make a note after your visit with a patient. The notes can be used as a hand off for the provider so they understand what is going on,” she says.
