Before you can give patients the information they need to make a good decision, you need to know something about the facilities on the list you give the patients.
"When case managers refer patients to the next level of care, they want to make sure that they are going to a place where they get the care they need to recuperate and avoid readmissions," 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 managers should be very familiar with the skilled nursing facilities that patients choose most often, and know the strengths and weaknesses of each, 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.
When Nazir was talking to a group of about 25 case managers and social workers, he asked how many of them had ever visited a skilled nursing facility. "Only three people raised their hands. They had no idea where they were sending people," he says.
Visit the facilities whenever possible and compile information on the facilities, what services they provide, what outcomes patients who go there have, readmission rates, staffing, and other information, Nazir says.
Case management departments should be keeping track of which providers have the most readmissions, Cunningham says. "Case management leadership has to take a role and understand what is driving their readmissions and where it is happening," she adds.
Develop a way to track readmission rates by providers, how many patients a provider accepts and declines, how quickly they respond, and how many times they fail to respond, she says. "Electronic discharge planning programs are an excellent way to track this information," Cunningham says.
If you don’t have an electronic discharge planning tool, create a table on paper that shows the providers to which you refer, readmission rates, and what services they provide, Cunningham suggests.
Case management leaders should treat the facilities owned by or affiliated with their hospital the same way they do other providers and analyze their readmissions and work with them to improve transitions, Cunningham says.
"Case managers tend to assume that their hospital’s facilities are good, but as we consult with hospitals we sometimes find that the hospital’s own home health agency has a higher readmission rate than other providers," she says.
Hospitals need to form partnerships with post-acute providers so they can work together to properly implement the discharge plan and collaborate on ways to prevent readmissions, Cunningham says. "In developing these partnerships, patient choice should always be in place for referrals to home health or skilled nursing facilities," she adds.
"In best-practice case management departments, the case manager leaders have already met with the post-acute providers that receive the most referrals and work with them to improve transfers and reduce readmission rates," says Cunningham, who recommends meeting quarterly or every six months with post-acute providers.
