Discharge Planning
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ICU to Long-Term Acute Care: Seamless Transition, Fewer Readmissions
When a seriously ill patient has not stabilized in the ICU, the next step may be a long-term acute care hospital like Spaulding Hospital Cambridge — which often is a difficult transition. Six years ago, Spaulding joined nearby Brigham and Women’s Hospital in creating the Integrated Patient Centered Care in Chronic Critical Illness program to provide a seamless transition of care for these patients and their families.
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How to Provide Culturally Competent Care
With the increased diversity among today’s hospital patients, case managers must be careful to understand each patient’s culture. People coming from different countries have different expectations of the healthcare system.
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Focusing on Social Determinants of Health Can Reduce ED Revisit Rates
A case management program that focuses on social determinants of health helped a hospital system reduce revisit rates in its ED. The ED’s revisit rate dropped from 6% to 3%.
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Program Targeting Skilled Nursing Facilities Reduces Readmission Rates by 25%
A study from Mount Sinai Health System in New York City revealed that 25% of patients who were transitioned to a skilled nursing facility (SNF) returned to the hospital within 30 days. The organization employed case management solutions to achieve a 20% reduction in the 30-day readmissions from SNFs.
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The Case Manager’s Toolbox: The Essential Skills of an Effective Case Manager, Part 1
RN case managers and social workers are key advocates in the delivery of quality healthcare. Their broad skills and training allow them to assess patients’ needs and work well with families and other members of the healthcare team. Negotiating, collaborating, communicating, team-building, precepting, educating, and consulting are the basis of what a successful case manager brings to the care setting each day. This month will begin a discussion of the skill sets every case manager and social worker should possess to be as effective in the role as possible.
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Program Tailored to Reducing Senior Patient Readmissions
A program in the Chicago area is demonstrating the value of tailoring discharge plans to the particular needs of elderly patients with little support outside the hospital. These “solo seniors” often face complex medical challenges after discharge and can experience high rates of readmission without help from family and friends. With hospitals facing significant penalties from 30-day readmissions, the program could be a model for hospitals to emulate.
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Case Managers Can Help Patients With Autism Spectrum Disorder
A hospital’s strange sounds, sights, and people can be overwhelming for a child with autism. But a case manager who watches for behavioral cues — and listens carefully to parents — can help that child cope more easily.
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Case Managers See an Influx of Elderly Patients in the ED
As baby boomers shift into their senior years, hospital EDs are seeing increasing numbers of older patients, a trend noted by a care coordinator at the Cleveland Clinic. These older, at-risk patients need case management services.
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Pulmonary Maintenance Programs Reduce Readmissions, Lower Costs
A hospital-based pulmonary maintenance exercise program can help patients with chronic lung conditions improve their exercise tolerance and regain some lung function, while reducing readmissions, according to the authors of a recent study. The potential cost savings are significant as well.
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An Escalation Team Can Improve Care for Complex Cases
Patients with complex needs can stretch the resources of even the most experienced case manager. These tend to be patients who have been admitted via the ED, not elective admissions. They are ready for discharge, but various barriers can cause complications.