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A family’s experience uncovers the need for care managers in the transition process

December 17th, 2018

Can we talk? Of course we can! But can we communicate? Ah, that’s a bit trickier, especially when one is navigating the discharge of a recovering yet fragile post-surgical patient from the hospital after a lengthy stay.  Requests for prescriptions, products, services and even simple explanations become an unnecessary challenge and, dare I say, a comedy of errors at times, as basic yet urgent needs for the patient must accommodate the whims, schedules, mismanagement and miscommunication of the various healthcare personnel and processes in the discharge chain.

Never has the need for care management been more evident than with the discharge of a patient on multiple prescriptions who has received care from 10 physicians, two nurse practitioners, and an assortment of nurses. Add onto that the need for physical therapy, occupational therapy and a variety of durable medical equipment (DME) and home health supplies and the care management demand skyrockets.

Following a three hour wait for a hospital discharge, both patient and family caregiver just want to go home; instead, there are detours to the medical supply store where, unsurprisingly at this point, the prescription for a hospital bed and platform walker have not yet been received, despite a nearly 36-hour notice that the patient was being discharged. Again, can someone say care management and care coordination?

When the faxed prescription arrives, it is too late to get the hospital bed because the agency that actually provides that piece of equipment closes at 4 p.m. and it’s now 3:55 p.m.  Necessity is the mother of invention, though, and a queen-sized mattress and box springs lugged down a flight of stairs to the first floor by primary and secondary caregiver provide the exhausted patient a familiar setting to doze – likely better in the long run for a good night’s sleep. (And certainly, much cheaper; the monthly bed rental is $125, but the actual cost skyrockets when considering the $195 delivery and pick-up charges, bringing one month’s use of a hospital bed to $585.) By the way, those outside of the healthcare system would be alarmed to see how much communication is still done by fax. In an era of HIT, FAX often remains king.

As an aside, a comment on the now common practice of nurses working 12-hour shifts. Seems to me that having the ability to work three days, twelve hours a day is, in itself, flexible. When nurses have flexibility within those three-day shifts, patient care can suffer due to lack of continuity among the nursing staff. For optimal patient care, strong consideration should be given to having a nurse work three consecutive 12-hour days, not a 12-hour day here and there within the workweek. While weekends are understandably harder to staff, why can’t the same nurses generally be assigned the morning shift and afternoon shift three days in a row during the week? Based on first-hand experience, the best example of continuity of care was surprisingly among the nurses’ aides, so valuable in the care process from a practical standpoint, yet because of their status on the care continuum, relegated to working traditional hours and, in so doing, bringing unexpected comfort to the patient and the family so desperate to see a regular pattern of care.

That leads me back to care management in the discharge process. Care managers are project managers of healthcare, trained to communicate with a variety of stakeholders, to make experience-based judgement calls about what is best for the patient and the patient’s family during the critical transition from hospital to home or skilled nursing facility (SNF) to home.  Many assume that hospital or SNF social workers currently serve this role, and they do try. But they are often just one piece of the puzzle, rather than the key coordinator. It’s care managers that are best suited to handle the myriad complexities of the discharge process. Let’s work to make care management a key component in the transitions of care and let’s ensure payers understand the key role of provider-delivered care management.

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