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It will be several years before the Centers for Medi-care & Medicaid Services (CMS) will require hospitals to use the Continuity Assessment Record and Evaluation (CARE) tool, but hospital case managers can start now to prepare for its implementation and to give CMS feedback on the tool and its use in various settings.
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"We need to do the same thing to empower patients and their families with information so they can be active participants in every transition of care," adds Skinner, a case manager for more than 20 years, principal consultant for Whitwell, TN-based Riverside Healthcare Consulting and a member of the National Transitions of Care Coalition.
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Everyone in the health care field has heard horror stories about patients' needs falling through the cracks when they transition from one level of care to another.
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A simple fall in a healthy person shouldn't result in multiple facial injuries, except if the patient was intoxicated, says Regina Curry, RN, an ED nurse at Thomas Jefferson University Hospital in Philadelphia. Instead, patients might break their wrist or skin their knees and hands from trying to break the fall, she says.
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Two cases from the Canadian Medical Protective Association, a mutual defense organization for 95% of Canadian physicians, illustrate the danger of patients driving home after ambulatory surgery:
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As part of its patient throughput initiative, Spartanburg (SC) Regional Health System set a goal of discharging 80% of patients by 2 p.m. and is conducting a series of Lean Six Sigma projects in an effort to reach that goal.
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A collaborative effort between Boston's Massachusetts General Hospital emergency department staff and the health system's post-acute facilities and home care agency moves patients out of the ED and directly into post-acute care, freeing up beds and improving patient throughput.
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A patient assessment tool being tested in a Medicare demonstration project is intended to standardize the information providers share as patients transition from one level of care to another.
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At a time when case management departments all over the country are facing cuts in staff or just remaining stable, DCH Health System in Tuscaloosa, AL, recently added four 0.7 FTEs to the case management departments of its two largest hospitals.
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In addition to giving your administration a list of roles, provide specific and detailed definitions and outline the functions your department performs for those roles, says Toni Cesta, RN, PhD, FAAN, vice president, patient flow optimization for the North Shore-Long Island Jewish Health System and health care consultant and partner in Case Management Concepts LLC.
