The HeartBeat of Case Management Case Managers: A Key to Reducing Readmissions Jennifer L. Ellsworth, MSW
W ith the new Medicare penalties and the release of Centers for Medicare and Medicaid Services (CMS) grant funding, preventable readmissions have quickly become a priority on health care agendas across the nation. Hospitals nationwide are asking questions: How can we reduce our readmission rate? How can we more safely transition our patients? How can we help patients optimize their health care in the community once they leave the hospital? There are no simple answers to these questions, but the first step is to answer a different question: What factors contribute to the readmissions in our hospital? With specialized training in active listening, motivational interviewing techniques, thorough assessment skills, and an invaluable awareness of the patient care continuum, nurse and social work case managers are uniquely equipped to assess and address readmissions, getting to the bottom of that very question. Case managers play a crucial role in today’s health care environment, and they are increasingly involved in readmission prevention efforts. Case managers are a natural fit for this role, as their strengths lie in the ability to effectively guide the patient through a hospital stay, reduce the fragmentation of care delivery across the entire continuum, and increase the quality of care provided. To further explore the parallels between case management skills and readmission prevention efforts, let us look at what research shows to be key factors in preventing readmissions: The intent of this column is meant to speak to the heart of case management: our joys, our struggles, and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Mindy Owen at:
[email protected] or Teresa Treiger at:
[email protected] Address correspondence to Jennifer L. Ellsworth, MSW, DHMC Office of Care Management, 1 Medical Center Drive, Lebanon, NH 03756 (
[email protected]). The author reports no conflicts of interest. DOI: 10.1097/NCM.0000000000000092
• Clear communication and a multidisciplinary team approach to care. • Education about disease process and symptom management techniques. • Medication reconciliation and clear documentation of medication regimen. • Ensuring that the patient has adequate social support, and including the caregiver in the initial plan of care and the transitional planning process. • Advance care planning and discussions of advance directives, with patient and family preferences being respected. • Identification of barriers regarding adherence to discharge plan, and providing methods to overcome these challenges. • Comprehensive transitional care planning, communication, and documentation. • Timely postdischarge follow-up with a primary care physician and/or specialists. Social work and nurse case managers are expert collaborators, enhancing communication, efficiency, and effectiveness of care delivery. Furthermore, case managers are skilled in facilitating positive communication between patients, families, and medical team members, and establishing rapport with the patient and family. The case manager’s connection and physical presence with the patient complements the patient’s relationship with their multidisciplinary team, facilitating conversations and engaging them in an exchange of questions and answers. Furthermore, the positive communication helps nurture a patient-centered care environment where patients feel empowered, comfortable, safe, and willing to share their thoughts, goals, and feelings. It is with unique training in active listening and motivational interviewing that case managers can explore a patient’s goals and desired outcomes, as well as their fears and potential obstacles. The rapport developed between patients and case managers is the foundation of a thorough and successful assessment. Not only does the assessment provide information needed for the transitional planning process, but it also identifies barriers and delays that may need to be problem-solved. In addition, other Vol. 20/No. 3
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The HeartBeat of Case Management members of the medical team rely on the assessment skills of case managers to get a full understanding and holistic snapshot of a patient’s situation. This is particularly useful when assessing a patient who has been readmitted. The goal of a readmission assessment interview is to explore factors that led to the readmission, including education about the disease process/symptom management, physician followup, medication management, nutritional needs, and access to transportation, in-home services, and discharge planning. Moreover, to truly understand the contributing factors of a readmission, it is essential to hear the patients’ perspective; case managers are able to assess needs on the basis of the conversation: • What do you believe contributed to your readmission? • Walk me through your day—what happened? • What do you understand about your diagnosis? • Did you see a doctor after you were last discharged? • Do you take any medications at home? Do you have any issues getting your prescriptions filled? What over-the-counter medications or supplements do you add to your daily dose? • Are you on a special diet? Are you able to follow this diet? Tell me about your access to, and preparation of, food. • Do you currently have any assistance or services at home? • Who are your main supports once you return home? To demonstrate the critical role case managers play in readmission prevention efforts, let us consider the case of George, a 78-year-old man with chronic obstructive pulmonary disease (COPD), now listed as a focused disease state regarding readmissions, per the CMS. I met George as part of a new readmission reduction initiative on his eighth admission to the hospital in a 2-year period. He had an additional nine emergency department visits during that time. The primary problem listed for each of the 17 total admissions was COPD exacerbation/shortness of breath. My goal in meeting with George was to further assess his frequent readmissions and identify barriers to safe discharge. My very first question to George was, “What do you think caused your admission to the hospital?” George explained that he and his wife go on errands multiple times each week and he was sure that his readmissions were directly related to these outings. After asking for further clarification of the connection between the outings and his admissions, George explained that he does not have a handicapparking pass, so he and his wife have to park very far away from the stores. By the time he walks from the 148
car to the store, he is gasping for air, he feels like he is drowning, they call 911, and the trip ends without groceries, but rather a ride to the local hospital in an ambulance. We then began to talk a little bit about how he understood his shortness of breath in the context of his illness. George proceeded to ask me, “What is COPD?” Through our discussion, it became clear that George did not have an understanding of his diagnosis, nor could he teach-back skills to manage his symptoms. Moreover, through my assessment, I discovered that George had neither a primary care doctor nor a pulmonologist. He also informed me that he did not have any oxygen at home, though he was told at some point over the previous few months that it would be a good idea. He discussed how overwhelmed and stressed his wife seemed, as she was his primary caregiver. He worried about her health and wished that he was not such a burden on her. After talking further with his care team, I understood that George was likely nearing the end stages of his illness, and his prognosis was limited. Until this point in his illness, George had not had an advance care planning discussion, nor had he learned of palliative or hospice care services. I took the new information that I had learned about George and his situation and worked with the multidisciplinary team to address his needs. I was able to get him connected with a new primary care physician and scheduled his first appointment, within 2 weeks of his discharge from the hospital. George was also connected to a pulmonologist, to further discuss home oxygen needs. I ensured that he had a means of transportation to get to his appointments. He was introduced to a nurse educator, who was able to give him more information on COPD and teach him symptom-management skills. The nurse case manager met with George and his wife to discuss discharge planning; she talked with George about visiting nurses and what benefits he could derive from their involvement. George accepted visiting nurse homecare services for the first time in his eight admissions. The primary team also requested a palliative care consult to further discuss goals of care. George and his wife met with the palliative care team, who were able to give him a realistic expectation of his prognosis, discussed his care wishes, and educated him and his wife about hospice services. In addition, I provided George and his wife with an application for a handicap-parking permit, along with instructions for submission. Finally, I made a home visit to George, a few days after his discharge, to support his caregivers, and to reinforce the new connections, information, and resources.
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The HeartBeat of Case Management George was admitted to the hospital 2 months later, again for COPD exacerbation. He and his wife spoke about their much-improved quality of life since his last hospital stay, and were particularly appreciative of the in-home support services. However, during this admission it became clear that his disease had progressed and it was time to consider a less aggressive approach to care. George and his wife remembered talking with the palliative care team about hospice, and they felt it was time to make that transition. George returned home with hospice care, where he died peacefully 1 month later. His wife cited the outstanding hospice care and support as a gift to both her and George in the last weeks of his life. As George’s case shows, nurse and social work case managers’ expertise in care coordination, communication, and assessment are vital in preventing readmissions and improving quality of life as defined by a patient and family. To ensure that our patients
receive the best possible care, we need to employ our uniquely skilled nurse and social work case managers to explore the drivers of readmissions within hospitals by assessing patients and engaging other providers in the discussion. Once barriers are clearly identified, specific goals can be established, system processes can be developed or changed, and initiatives can be set into motion to provide patients with safe transitions at each step of their medical journey. Using this specialized training to improve care transitions and patient experience is what makes my role as a social work case manager rewarding and it is why I do what I do! The intent of this column is meant to speak to the heart of case management: our joys, our struggles and our lessons learned. Please send your thoughts and ideas to us so we may include them in future articles. Mindy Owen at:
[email protected] Teri Treiger at:
[email protected] Jennifer L. Ellsworth, MSW, is a clinical social worker within the palliative care team at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. Throughout her social work career, she has focused on the geriatric population, transitions of care, and community support. Before her position at Dartmouth–Hitchcock Medical Center, she developed and implemented a $3.2-million CMS Care Transitions Grant that funded a hospital—wide transitions of care program. Jennifer’s contribution to this column reminds us of how we manage and support our patients individually while focusing on “key indicators,” such as readmissions.
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