Case Management Insider
September 1, 2013
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Case Management Insider
Back to Basics: A Day in the Life of a Hospital Case Manager Part 2
By Toni Cesta, PhD, RN, FAAN
Introduction
In last month’s Case Management Insider we began to review the case management process. The process has a total of eight steps, and we completed our review of six of them. This month we will continue with the final two steps in the case management process and discuss best practices for doing an admission assessment. We will also review a case study that should help you in applying the steps we have been reviewing!
Step 7: Patient Discharge and Disposition
By the time we have reached step 7, the patient should be close to ready for discharge. As discussed last month, the patient should be reviewed daily for any changes that may impact on the discharge plan’s destination. Step seven requires one last look at the selected destination for assurance that it still meets the patient’s post-discharge needs and has been approved for payment by the patient’s insurance plan or provider. Once all elements have been determined as correct and appropriate, the patient’s transition to the next level of care should take place.
The transition of the patient is an important step in the case management process. There are important pieces of this step to keep in mind and ensure that they are completed before the patient leaves the building. These would include the following:
- Have the patient and family agreed to the discharge plan and destination?
- Have they been educated as to anything they need to know regarding medical care, medications and care at home?
- Are all post-discharge arrangements in place?
- Has the patient been given a written list of instructions for care at home?
- Have their medications been reconciled?
- Do they have a follow-up appointment with their primary care physician or specialist within five days of discharge?
- Do they have a written communication outlining when their physician follow-up appointment is, and do they have a way to get to the appointment?
All of these elements help to provide a smooth transition for the patient and family. Never assume that the patient and family know all they need to know. Repeating the educational information multiple times will help to improve their retention of the information. All of these elements, if completed properly, will also help to reduce the probability of the patient’s return to the emergency department and potential readmission to the hospital.
Step 8: Repeating the Process / Ongoing Evaluation
Despite our best efforts and intentions, sometimes our patient’s condition changes at the last minute. In some other cases, the family may change their mind or suddenly be unable to care for the patient at home. This is when you may have to move to step eight. Step eight requires that you take a step back in the process. This may mean you will have to go back one, or multiple steps. As discussed last month, the case management process is not always a linear one, and in some cases, the need to circle back happens at the very end of the process. If the patient’s condition or situation changes in such a way that the discharge plan is no longer a safe one, then the case manager has an obligation to stop the discharge until the plan has been revised as necessary. While this may delay discharge and increase the length of stay, it will most likely be the better option toward ensuring that the patient has a safe and appropriate discharge destination. The delay may be hours or days, depending on the cause. Either way, it is better to delay than have the patient back in the emergency department and readmitted to the hospital.
Case Management Admission Assessment
The case management assessment sets the stage for the implementation of the case management process that we have just reviewed. It is a critical first step! In the earlier case management models, patients were screened, and if they met specific criteria, then they were followed by a case manager. In today’s contemporary models, we now need to case manage every patient. In order to do this adequately, then every patient must have a case manager and must be assessed by a case manager. Not unlike the staff nurse or the physician in the hospital, this admission assessment must be done by the case manager on the day of admission. In the past, the assessment was done up to three days after admission. Later, some hospitals moved this to within twenty-four hours of admission.
Initial Assessment Must be Completed on Day of Admission
Today’s nationwide average length of stay is around 5.1 days. Within a five-day length of stay, the case manager has a lot to do, as evidenced by the myriad of issues to be addressed in the case management process. Waiting even 24 hours can delay the discharge planning process and extend the length of stay for those patients who will be requiring continuing care services in the community.
The case management admission assessment informs the case manager regarding a number of important data sets, such as:
- Where the patient was admitted from.
- What their social situation is including social supports.
- What their mental status is.
- What their financial status is.
- What day the patient may be discharged.
- Where they may be going after discharge.
- What their clinical status is.
- The case manager should be gathering this information from a variety of sources. These would include:
- The prior medical record.
- The current medical record.
- The patient.
- The family / social supports.
- The community physician.
- The admitting physician.
- The staff nurse.
Having a standardized admission assessment form ensures that standard information is being collected on every patient in a uniform manner and no information is being forgotten or overlooked. Having a form also streamlines the process, taking the guesswork out of it. The data can be collected in the electronic medical record, in the case management database, or on paper. The method of collection will depend on your hospital’s systems and available information technology support. If you collect the data in a case management software application, then you must be sure that the data transfers over to the electronic medical record, or paper medical record.
The Conditions of Participation for Medicare require the following:
"Screen patients to determine their risk for readmission, assess at-risk patients for discharge needs, create a discharge plan, and implement a discharge plan." (www.cms.gov/cfcsandcops/)
A case management assessment can accomplish both the initial risk assessment as well as the initial discharge plan, thereby combining two steps into one.
- Admission
- Patient care rounds
- Individual case conference with members of the health care team
- Inquiry from patient/family/physicians
- Review of medical records
The following categories should be included and can be used to format your own case management admission assessment form:
Patient Information
• Patient demographic information
Admission Information
• Admission information including
- Admit date
- Admit diagnosis
- Admitting service
- Attending physician
- Admit source
Financial Information
• Financial information
- Insurance
- Plan number
- Medicaid eligibility
Spoken Language(s)
Source of Admission
• Admitted from:
- Acute rehab
- Ambulatory surgery
- Another acute care facility
- Behavioral health
- Emergency department
- Home
- Home with home care
- Long-term care
- MD office or clinic
- Sub-acute
Significant prior medical history
- Angioplasty
- Behavioral health
- Substance abuse
- Blindness
- CABG
- CAD
- Cancer
- Cardiomyopathy
- CHF
- COPD
- Deafness
- HIV / AIDS
- Hypertension
- Pacemaker
- Paraplegic
- Quadriplegic
- Renal failure
- Stroke
- Vent dependent
- Other
- None
Mental status prior to admission
- Alert
- Not alert
- Confused
- Oriented x 1
- Oriented x 2
- Oriented x 3
Ability to make needs known:
- Able
- Unable
Living arrangements
- Adult home
- Apartment
- Assisted living
- Group home
- Homeless
- House
- Naturally occurring retirement community (NORC)
- Nursing home
- Shelter
- Stairs
- Elevator
- Other
• Lives:
- With adult children
- With dependent children
- Alone
- With other family
- With spouse / significant other
- Domestic partner
- Other
• Support system
- Name
- Telephone number
- Relationship
• Can patient return to prior living arrangements:
- Yes
- No
Activities of daily living:
- Dependent
- Independent
• Assistive device
- Yes
- No
• Which assistive device:
- Cane
- Oxygen
- Walker
- Other
Prior resource use:
- Children’s services
- Adult services
- Adult day care
- Behavioral health services
- Dialysis center
- Home health care services
- Infusion therapy
- Meals on Wheels
- Medication assistance program
- Non-medical home care
- Support group
- Health Home
- Medical Home
- House calls
- Other
- None
Does patient have a primary care provider:
- No
- Yes
PCP Name ___________________
Address ______________________
Phone number ________________
Social Work triggers
- Abuse Domestic violence
- Abuse and/or neglect of a child
- Abuse and/or neglect of elder/adult
- Abuse sexual assault
- Adjustment to illness/ Difficulty coping
- Behavioral management problems
- Crime victim
- Cultural and/or language issues
- Drug abuse
- Ethical concerns
- ETOH abuse
- Family concerns and/or conflicts
- Guardianship
- Homeless requesting intervention
- Hospice placement
- Inadequate social support
- Inadequate financial support
- Long-term care placement
- Major illness causing lifestyle change
- Multi-system trauma
- Name of patient unknown
- Non-compliance issues
- Poor prognosis
- Shelter placement
- Uninsured
- Undocumented
- Other
- None
• Referred to Social Work:
- No
- Yes
Name _______________________
Contact info __________________
Home Care Triggers
• Patients requiring assessments/education relating to:
- New diagnosis
- New medications or change in medications
• Change in patient’s physical environment and/or new assistive device.
• Patients with unstable disease process; cardio/pulmonary, diabetes, neurological, neuromuscular, metabolic, cerebrovascular, cardiovascular, renal, cancer, pediatric/including asthma, premature infants, psychiatric
• Patients with open wounds, VAC wound care, pressure ulcers
• Patients with ostomy, trachs, feeding tubes
• Patients with drainage tubes and catheters
• Patients requiring I.V. and injectable drug therapies
• Patients with recent change in functional status including but not limited to; falls, paralysis, fractures, amputation or other physical impairment, change in custodial needs, ortho, neuro and/or deconditioned diagnosis
• Patients with pain control management
• Patients with end-stage disease and palliative care needs
• Patients with new oxygen and/or nebulizer treatments
• Patients receiving any type of home care services, i.e., CHHA, LTHHCP, PCA, private care, at time of hospital admission
• Patients re-hospitalized within 60 days and/or known history of repeated hospital readmissions.
• Patients requiring expedited discharges (EHD/Bridge Program)
The above Guidelines can be utilized at:
- Admission
- Patient care rounds
- Individual case conference with members of the health care team
- Inquiry from patient/family/physicians
- Review of medical records
Initial Anticipated Discharge plan
- Acute Care Transfer
- Acute rehab
- Adult home
- Assisted living facility
- Home
- Home hospice
- Home with home care (skilled)
- Home with home care (home attendant)
- Home with home care (infusion)
- Skilled nursing facility - chronic care
- Skilled nursing facility chronic care with hemodialysis
- Skilled nursing facility custodial
- Skilled nursing facility skilled
- Sub-acute rehab
- Traumatic brain injury unit
- Other
- Not known
Case Study The Case Management Process
This case study outlines the differences in planning for a patient discharge depending on the patient’s age and clinical condition. These factors, along with the patient’s response to care while in the hospital, will help to inform the case manager as to the best possible discharge destination for the patient. The process also requires that the patient is re-assessed on a daily basis.
Day 1: Patient assessed
Initial discharge plan: Home after exploratory laparoscopy
- Young, healthy patient or
- Elderly, healthy patient or
- Young, medically complex patient or
- Elderly, complex patient
Day 2: Patient re-assessed. No changes in discharge plan.
Day 3: Patient re-assessed. Plan is still to send patient home.
Day 4: Patient begins to show signs of sepsis. Discharge plan is now:
- Young, healthy patient: Home
- Elderly, healthy patient: Home with home health, possibly durable medical equipment (DME)
- Young, complex patient: Home with home health, possibly durable medical equipment (DME)
- Elderly, complex patient: Skilled nursing facility
Day 5: Patient in Intensive Care Unit (ICU) with circulatory and respiratory collapse.
Discharge plan should be reassessed as the patient’s condition has changed significantly and the length of stay has been extended accordingly.
- Young, healthy patient: Home with home health, possible durable medical equipment
- Elderly, healthy patient: Skilled nursing facility
- Young, complex patient: Skilled nursing facility
- Elderly, complex patient: Long- term acute care facility (LTAC)
Day 6: Patient continues to recover
Day 7: Patient continues to recover
Day 8: Patient recovering. Plan to transfer to surgical unit with telemetry monitoring on day 9. Drains in place. Stage 2 pressure ulcer.
- Young, healthy patient: Home with home health, possible durable medical equipment
- Elderly, healthy patient: Home with home health, possible durable medical equipment, or skilled nursing facility
- Young, complex patient: Home with home health, possible durable medical equipment, or skilled nursing facility
- Elderly, complex patient: Skilled nursing facility or long-term acute care facility (LTAC)
Day 9: Patient recovering on surgical unit. Telemetry discontinued. Drains in place. Pressure ulcer improving.
- Young, healthy patient: Home with home health, possible durable medical equipment
- Elderly, healthy patient: Home with home health, possible durable medical equipment or skilled nursing facility
- Young, complex patient: Home with home health, possible durable medical equipment, or skilled nursing facility
- Elderly, complex patient: Skilled nursing facility or long-term acute care facility (LTAC)
Day 10: Patient recovering. Drains in place.
Day 11: Plan for discharge tomorrow with drains in place. The discharge plan is adjusted to reflect the patient’s continued recovery and reduction in complexity.
- Young, healthy patient: Home with home health
- Elderly, healthy patient: Home with home health, possible durable medical equipment
- Young, complex patient: Home with home health
- Elderly, complex patient: Skilled nursing facility
As can be seen above, the discharge plan has been reduced significantly from the higher possible discharge destination to the lower. This reduction is reflective of the patient’s continued recovery and positive progress.
Our case study demonstrates the need to continuously reassess the patient’s clinical condition and response to treatment. In this example, had that not been done, the case manager would have spent a significantly greater amount of time on day 11 readjusting the plan to reflect the patient’s condition at that time.
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