Patient Transitions—It’s Not Just Discharge Planning Anymore
By Toni Cesta, PhD, RN, FAAN
Introduction
Prior to the advent of the inpatient prospective payment system (IPPS), the discharge planning process was simpler and slower. Patients generally stayed in the hospital until they were well and then went home. Occasionally, patients needed home care or were placed in long-term skilled nursing facilities. Once the IPPS system was implemented by the Centers for Medicare & Medicaid Services (CMS) and hospitals had to be more aware of their lengths of stay and resource consumption, discharge planning became a much more important process.
The Continuum of Care
Never has the continuum of care been more important than it is now. The continuum is defined as an integrated system of healthcare support services that assures comprehensive and coordinated services for patients. Unfortunately, healthcare has been slow to create the linkages that are so important in the management of high-risk patients so that they do not have unnecessary admissions, readmissions, and emergency department visits. While the services are available, often there is poor or no communication between service providers across the continuum.
The case management process has become the chief integrating mechanism for patients across the continuum. Other coordination-of-care mechanisms include disease management, risk stratification, accountable care organizations, medical homes, and health homes.
Today’s integrated delivery systems must include infrastructures to support the care of patients across the continuum as well. These would include information systems, acute care and community case management, a physician-hospital management structure, etc.
Levels of care should include:
• acute care;
• sub-acute care;
• home health;
• skilled nursing;
• hospice;
• adult day care;
• physician services;
• ambulatory care;
• wellness centers;
• urgent care centers;
• emergency departments;
• respite care;
• home maintenance services;
• infusion/nutrition services.
These services may be part of your organization’s owned services, or they may be service organizations with whom you have a relationship. Organizations with whom you do business and who provide patient care services are not vendors and should not be defined as such. They are patient care providers. The continuum of care should be used to reduce cost by ensuring that the patient is in the least expensive, most appropriate setting based on his or her clinical needs and level of risk for poor outcomes. The determination of the appropriate level of care is a decision shared between the physician, the direct care providers, the patient, and the case manager.
Therefore, levels of care include levels of cost. The level of care should be matched to the patient’s clinical needs and should represent the lowest-cost level of care available and appropriate.
Lower cost:
- patient self-directed care;
- preventive services;
- primary care including physician and allied services.
Moderate cost:
- specialist services;
- outpatient clinics;
- home care.
Higher cost:
- acute care;
- emergency departments;
- centers of excellence;
- skilled nursing;
- sub-acute.
Hand-Off Communication
Due to the poor communication processes described above, many organizations have begun to realize the importance of hand-off communication. Hand-off communication refers to the process of transferring a patient from one care provider to another. It includes the transfer of patient information to the next provider. Hand-off communication must include verbal as well as written communication. Good hand-off communication processes provide for appropriate transition of the patient from one level of care to the next. This may include moving to a higher level of care as well as a lower level.
Case manager and social worker hand-off points occur throughout the hospital stay. Examples include:
• admission circumstances;
• admitting diagnosis;
• physician coordinating care;
• interdisciplinary team conferencing;
• physician;
• family contact;
• discharge planning;
• discharge barriers;
• payer/funding sources;
• medical necessity criteria;
• physician advisor;
• consultant issues and contacts;
• staff nurse.
Communication can include visual images, body language, nonverbal, verbal, and written forms. In hand-off communication in healthcare, it generally takes the form of written and verbal communication, as the providers are often not physically together when the transfer of information takes place. This adds to the complexities of hand-off communication. Even when people are physically together and transferring information, there are still inherent challenges in the transfer of information. When the face-to-face portion of communication is lacking, the likelihood of miscommunication is greater. Errors that can take place include misinterpretation, misunderstanding, rejected, distorted, and non-heard information. This makes the need for verbal communication, in addition to written, even more important.
Nonverbal Communication
As case managers, we may use a variety of methods for nonverbal hand-off communication. It becomes easy to hide behind the many forms of nonverbal communication. Hiding may include information that you may not really want the receiver to obtain, or a lack of desire to confront the receiver of the information. In today’s electronic world of communication, you can send information to third-party payers and other care providers via fax, email, electronic fax- attach, letters and memos. These are the most common forms that are typically used by case managers in the transfer of information. As we have seen, these forms of communication in the absence of a verbal communication can result in misunderstandings.
One point of clarification is worth mentioning here. When sending clinical reviews to third-party payers, today’s best practice is to fax or electronically send the information using an electronic clinical review tool that provides objectivity in the clinical review based on national clinical standards for levels of care. However, it is important to note that when you believe that the case warrants an additional verbal exchange of information, you should take the additional effort to do so. Most reviews are standard and do not require this extra step. Whenever you believe that the case is more complex than usual, it is recommended that you make the additional effort of providing verbal information to the third-party payer. In the long run, this may save you a lot of back and forth, or reduce the likelihood of your receiving a denial of payment. In most instances, this will not be necessary.
Verbal Communication
For case managers performing discharge planning and transitional planning, it is imperative that the patient be handed off to the next provider both verbally as well as in writing. This can be difficult in certain circumstances in which you are not speaking directly to the next provider of care, but rather to an intake person or screening person. In either case, a verbal hand-off is always preferred. You should always try to use a consistent approach when transitioning via verbal communication. This helps you to be organized and ensures that you do not leave out any important information.
Some of the minimum data to be shared should include:
• brief clinical picture of the patient;
• any readmission patterns / frequent emergency department use;
• name of community case manager;
• name of primary care provider;
• benefit information;
• patient demographics;
• family caregiver information;
• family dynamics / issues;
• date of discharge;
• mode of transportation;
• any issues of negotiation.
You may want to create a "transfer form" in which you can put the key categories of information you need to transfer during the hand-off of communication. This will be for your personal use and does not need to go into the medical record. It can, if your department wants to make it an official document. You should, however, be sure to document a summary note in the medical record that includes all pertinent information related to the patient’s transfer.
Internal Transfers
Another important point of transfer for the case manager and social worker is the movement of the patient within the acute care setting. In the average hospital, more than 50% of patients are admitted through the emergency department (ED). The emergency department case manager and the inpatient case manager should have a process for hand-off communication. Patients admitted through the ED should be assessed by the ED case manager. This information should be placed in the patient’s medical record. In addition to this written hand-off, the ED case manager should provide a verbal exchange of information with the inpatient case manager.
The ED case manager can create a transfer form such as the one we discussed in the last section so that consistent and appropriate information is always exchanged.
Patients transitioning within the hospital from one nursing unit to another should always be handed off verbally as well as in writing. These transitions occur as the patient moves from a higher level of care to a lower one, or from a lower level to a higher one. For example, the patient may be taken off telemetry and transitioned to another nursing unit. Or the patient may become sicker and need to be moved to the intensive care unit. Because the patient is the center of the process, the hand-off of information between case managers should happen every time the patient changes locations within the hospital. By providing case management hand-off information, the case management planning and discharge planning processes can continue smoothly without delays. The process also reduces the amount of work the receiving case manager has to do to "get up to speed" on the case, thereby reducing the likelihood of an extension in the length of stay.
Weekends and Holidays
Your case management department probably has more limited staffing on weekends and holidays. If this is true for your department, then it is also likely that you have designated weekend staff or that the regular staff rotate through the weekends. In either case, when a small number of case managers are handling multiple patient care units, hand-off communication is critical.
Your department should have a standardized process for relaying information to staff providing weekend coverage. It is likely that the covering staff will not be able to follow every patient in the hospital, so hand-off communication for Saturday, Sunday, and holiday coverage should be done on Friday. The communication should include anticipated discharges, utilization management issues, any pending approvals, any clinical reviews that need to be done, and generally any information that you deem important for the covering staff to have.
If you have a case management software program, then this information can be transferred electronically. However, even if this information is in the software program, the covering staff will still likely need to be alerted to the specific patients that they need to follow up on.
The same logic should apply between the weekend and holiday staff and the weekday staff. Activities completed or pending issues should be communicated in the same way.
Communication Tips for Case Managers
Below are some tips and strategies you may want to consider as you become more aware of your communication patterns and strategies for hand-off communication.
• Too much information delivered too quickly will result in a poor-quality communication effort.
• The fewer people to whom messages must be relayed, the more effective the communication.
• Always keep yourself focused on the goals of your communication and do not get intimidated by hierarchical status when quality patient care is at stake. Seeking feedback and verifying the information conveyed will help you maintain power.
• If conflict is well managed, it can actually increase the effectiveness of an organization.
• In addition to improving your basic communication skills of reading, writing, listening, and speaking, case managers can improve their communication effectiveness by withholding judgment, avoiding inconsistencies and valuing all members of the team, inclusive of patient and family.
Patient Care Rounds
Another venue for hand-off communication is interdisciplinary patient care rounds. Best practice for patient care rounds includes "walking rounds." Walking rounds involves a discussion of the patient outside the patient’s room, and then the team presenting themselves to the patient and family at the bedside.
It is during the discussion outside the patient’s room that hand-off communication will take place between the case manager, social worker, and the rest of the interdisciplinary care team. You should come prepared to discuss the patients in your caseload and to obtain additional information from the other members of the care team.
Pre-Rounds Checklist for the Case Manager
The following list of items contains the data points that the case manager should have readily available when attending interdisciplinary care rounds:
1. Review patient status: inpatient/observation.
2. Determine whether the patient is meeting appropriate criteria and level of care.
3. Review prior living condition and anticipated discharge plan.
4. Identify barriers to discharge including insurance coverage, family, housing, etc.
5. Determine the status and availability of the family caregiver if appropriate.
Pre-Rounds Checklist for the Social Worker
The list of items below contains the data points that the social worker should have readily available when attending interdisciplinary care rounds:
1. Review any psychosocial issues.
2. Identify any financial issues.
3. Determine if there are any barriers to care, either in the hospital or after discharge.
4. Provide any ongoing interventions.
5. Update the anticipated discharge plan.
When the team presents itself in the patient’s room, the team leader should do the following:
1. Sit next to the patient.
2. Introduce the team by name and discipline.
3. Discuss the plan of care with the patient and family if they are present.
4. Discuss the anticipated length of stay and day of discharge.
5. Discuss the anticipated discharge destination.
6. Ask the patient and/or family member if they have any questions.
Strategies for the Nurse Case Manager on Rounds
1. Reinforce information with the patient such as length of stay.
2. Discuss and/or reinforce the anticipated discharge plan.
3. Answer any discharge planning-related questions.
Strategies for the Social Worker on Rounds
1. Reinforce the discharge plan.
2. Provide psychosocial support.
3. Schedule time to meet with the patient and family privately if necessary.
Post-Rounds Activities for the Nurse Case Manager and Social Worker
The following activities should be completed at the conclusion of rounds. These activities will help you to remain organized and in touch with the interdisciplinary care team:
For the nurse case manager:
• Clarify next goals of care as needed.
• Initiate discharge planning paperwork as appropriate.
• Verify patient status and level of care.
• Provide clinical medical necessity reviews based on information obtained on rounds.
• Document rounding (attendees and content of rounds) in the medical record.
• Communicate any discharge planning changes to next level of care providers — verbal hand-off.
For the social worker:
• Discuss discharge plan with the case manager and staff nurse.
• Document any interventions to barriers to care.
• Facilitate discharge planning process.
• Schedule time to meet with patients and family members as needed.
Community Case Management
On admission, you should determine if the patient has a community-based case manager. If so, you should be sure to provide hand-off communication to the community case manager as you move toward the day of discharge. This is important in ensuring that there are no gaps in care as the patient transitions back into the community.
Summary
Hand-off communication provides an important link for patients and care providers as patients transition across the continuum of care. Make it part of your everyday practice!
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