Many families spend more time and energy researching the best microwave oven to buy than they spend choosing a post-acute facility for their loved ones, says Alex Alvarez, RN, senior director of Network Care Management, Montefiore Medical Center’s care management organization.
It’s up to discharge planners to guide family members in choosing a facility that meets the needs of the patients and will produce a good outcome, he adds.
At Montefiore, the lead discharge planner, usually a social worker, works with the patients and family members on a discharge destination. "We give them a letter explaining that the next level of care is a skilled nursing facility and include a list of facilities that can provide the services they need," Alvarez says.
Case managers should start the discussion about post-acute choices early in the inpatient stay and involve the attending physician in discharge planning, says Arif Nazir, MD, associate clinical professor of medicine in the geriatric division at the Indiana University Medical School and an affiliated scientist at the Indiana University Center for Aging Research.
"Physicians are the only team member who understands all of the issues, such as how much care the patient requires, how often a patient needs to see a doctor, when the lab work needs to be done, and whether the patient would be a good fit for a subacute facility, a skilled nursing facility, or an acute rehabilitation facility," he says.
Talk to the attending physician on the first day of the admission to find out the patient’s expected discharge destination and inform the family. "Nothing bad will happen if you end up being wrong, but it could be disastrous if you try to line up a facility on the last day," he says.
"Case managers should assess patients on Day 1 and keep reassessing patients throughout the stay. Their needs may change and the level of care after discharge may change," says Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts.
If it’s likely a patient will need a stay in a skilled nursing facility, start talking with the family as soon as you’re aware of it, Cesta says. Give them a list of facilities early in the stay so they will have time to visit them, she says. Facilities that can’t meet patients’ needs should not be on the list, Cesta adds.
When it is appropriate, the skilled nursing facility choice list Montefiore Medical Center gives patients includes the five skilled nursing facilities that are working with the medical center on quality initiatives. (For details on the collaboration, see page 150.) "If the patients ask for advice, the social worker can indicate that Montefiore is involved in quality initiatives with these five facilities. It helps them make a more informed decision. Patients will go where they want to go, but we want to give them information so they can make an informed choice," he says.
If patients make a bad choice, case managers have the responsibility to move them in another direction, Cesta says.
"One of the roles of case managers is to be a patient advocate. If a patient or family has chosen a facility that won’t meet the patient’s needs, case managers should tell them that the facility can’t give the clinical level of care needed, and suggest that later, the patient may be able to move to a closer facility," she says.
If you are concerned about violating the patient choice regulations, develop a script to help your RN case managers and social work case managers to educate and guide the patients and family members to make appropriate choices, says Beverly Cunningham, RN, MS, vice president of clinical performance improvement at Medical City Dallas Hospital and a partner and consultant in Dallas-based Case Management Concepts.
"Case management leadership has to take responsibility for supporting their staff so the staff knows how communicate with patients to make sure they transition to the right place," Cunningham says.
Encourage family members to visit the facilities they are considering and give them guidance on what to look for, Nazir says. He recommends referring family members to the Nursing Home Compare website, which has a detailed checklist of questions to guide families during their skilled nursing visits as well as well as information on the facilities.
"Arm them with all the information you can that will help them make a good choice," he says.
