Catastrophically injured patients need management
Continuity of care speeds recovery, helps quality of life
Creating a plan of care for a catastrophically injured patient is a little like creating a patchwork quilt you gather up scraps from a lot of different places and stitch it together, says Jolynne "Jo" Carter, BSN, RN, CCM.
As catastrophically injured patients move through the continuum, communication is essential between providers at every level of care in order to ensure a smooth transition and continuity of care, says Carter, senior director of network services for Paradigm Management Services LLC, which contracts with workers' compensation insurers to manage the care of their catastrophically injured patients. Carter is responsible for supervising the company's 130 registered nurse case managers who provide on-site management throughout the country.
"The big key is organization and communication, knowing what needs to be done, and working together collaboratively with providers to make it happen. Case managers have an important role as patients transition between venues of care to ensure that their needs are being met and that nothing falls through the cracks," she adds.
Planning the care of a catastrophically ill patient should begin while the patient is still in the intensive care unit, Carter says.
"We start to work with the hospital case managers to determine the severity of the injury, what the patient's prognosis is, the implication of injury for this patient, and what the course of care is likely to involve," she adds.
"At first there is not a lot a case manager can do with the patient from a medical standpoint. We help sort out who is responsible for the payment and help support the family at the time of crisis," adds Anna Gibson, RN, CDMS, network manager for Paradigm.
To provide continuity as patients transition from one level of care to the next, Paradigm case managers work with the patient throughout the continuum of care, from the intensive care hospital to the rehabilitation facility, back home, into the community, and into productive activities.
The average length of a contract is 18 months, but network managers have followed patients for as long as four or five years, depending on their needs, adds Gibson, who is based in Atlanta and coordinates care for catastrophically injured patients throughout Georgia.
Working with hospital case managers
The nurses at Paradigm have a narrow focus, and their expertise is complemented by the hospital case managers who know how their hospital system works, what it takes to get specialist referrals, and what resources are available in the community, she adds.
"Hospital case managers are our lifeline into the facility. They are the key people who can get us the information we need to make sure that the patient gets everything he or she needs down the line. We have a good working relationship with them and collaborate on how to meet the patient's needs," she says.
Planning should begin early in order to move the patient through the system efficiently and cost-effectively, Gibson says.
"If the patient isn't meeting criteria to stay in the acute care hospital, he has to move on and you're not likely to get much notice," she adds.
Early in the stay, the Paradigm case managers meet with the hospital case manager and the treatment team to determine the patient's likely discharge destination and to coordinate services the patient will need. They identify the preferred provider network requirements and determine state jurisdictional requirements for workers' compensation cases or benefit plan limitations for health insurance carriers.
Gibson and Carter recommend transferring patients with spinal cord injuries or traumatic brain injuries to a specialized rehabilitation center where staff have the expertise necessary to care for the patient.
"A center of excellence may be more expensive in the beginning, but in the long run, we can document the savings in doing things right the first time. It's more cost-effective to send a patient to a center that deals with their particular injury all the time rather than sending them to a rehabilitation center that works with only a few catastrophically injured patients a year," she says.
For instance, if a spinal cord injury patient is fitted with the wrong power chair or the seating isn't correct, the insurer is likely to end up paying for decubitus ulcer treatment.
Surgically closing an ulcer takes roughly six weeks in the hospital at a cost of $75,000 to $100,000, Gibson points out.
"Power chairs typically cost $20,000, and if a patient has the wrong chair, it may have to be replaced," she adds.
Paradigm case managers work with individual carriers and try to work within the insurer's preferred provider network.
"But as case managers, our first job is to get the patient the care they need. Part of evaluating the options is to look at what provider can best meet the needs of the patient and to advocate for that venue of care," she says.
Planning for longer-term care
If the specialty rehab center that can provide the best care for the patient is not in the provider network, the case managers educate the carrier about the wisdom of sending the patient to a specialty center.
"We're going to be working with this patient and family for the next 18 months or so. We're not just interested in getting them to the next place of care. We want the next place of care to be an option that is going to provide them with the best possible outcome," she says.
The injured patient's family is an important part of the treatment plan and needs a lot of ongoing support, Carter says.
Families often are overwhelmed when they start thinking about the burden of caring for a catastrophically injured patient, Carter points out.
"We start dealing with the family right away. When the patient's condition stabilizes, they start thinking beyond medical issues to what their life will be like. The family knows that everything isn't going to be the same. It's a loss, and they have to adapt to it," she says.
The Paradigm case manager works as a team with the hospital case manager to help the family adjust to the changes that the injury will make in their lives.
"When you hear something from one person and you're stressed, you can't hear what you don't want to hear. But when the hospital case manager tells them something and our case manager comes behind them and repeats it, it helps the family understand what the patient's likely outcome will be," she says.
Family counseling
Catastrophically injured patients and their families need psychological counseling to help them cope with their loss and the changes in their lives, Gibson reports.
"At the centers of excellence, families see a psychologist as part of the treatment. If they need anything beyond that, we may pull in a psychiatrist. Workers' compensation may not pay for treatment for a family member, so we have to look to their insurance carrier," she says.
Once the family is back home, Gibson sets up family counseling.
"Spinal cord injuries and traumatic brain injuries mean major adjustments in relationships. Suddenly the spouse becomes the caretaker. Many times I put the family in touch with a support group to help them with the transition," she says.
Establishing a good relationship with the family helps case managers facilitate transitions and ensure that patients are getting everything they need as they move from one venue of care to another.
"The family realizes that we are there to provide assistance and act as a partner in their recovery. They feel comfortable telling us things that are bothersome to them when they might not mention them to a doctor," she says.
At the same time, the case manager can pass on information about the patient and family dynamics to the internal case managers and treatment teams throughout the continuum of care.
"Someone who spends a fair amount of time with the patient and gets to know them and their family can give the downstream providers better knowledge about what might be successful, what we have tried, and what we haven't," she says.
It's when patients transition from one facility to another that glitches occur, Carter says.
"We are hypervigilant about the transitions of care. One of our goals is that every time the patient changes physical location, our case manager will be on the site within one day to ensure that the new environment is safe and meets patient needs. Our attention to this comes from experience," she says.
For instance, several years ago, a spinal cord injury patient was transferred from a rehabilitation center back to acute care and lay on a stretcher in the emergency room for eight hours.
In other cases, the patient is discharged to home on the weekend and the home care nurse doesn't show up or some of the needed equipment doesn't arrive.
"Many glitches occur during transitions of care. Case managers can work to ensure that nothing falls through the cracks," Carter says.
"The hospital case managers are our partners inside the hospital to make sure these problems don't come up and when they do occur, ensure that they are handled quickly. We want to ensure that all patients who leave the hospital can do so safely," she adds.
One of the keys to managing the care of catastrophically injured patients is to have reliable information about the patient and his or her condition and to combine that information with your own assessment skills to get the total picture of the patient and to begin to create a plan of care, Carter says.
"Coordinating all the resources the patient needs takes a lot of communication," she says.
Find out what patients want to do and match up their therapy with their goals, Carter suggests. Talk to the therapist and treatment teams about ways to maximize patients' function based on what they want to do.
"When patients are engaged in working toward something they want to do, they are more likely to succeed. Find out what they liked to do before they were injured and help them work toward that goal," Carter says.
For instance, if someone has never cooked a meal in his life, it may not make sense for him to work on cooking as part of his therapy.
"Catastrophically ill patients want to get their life back and reclaim what they've lost," she says.
In the case of injured workers, reclaiming what they have lost extends to their ability to return to work, she says.
"It is important to assess what the provider treatment team believes is possible and work with their employer on bringing them back to work, even with job accommodations. The hospital case manager is a vital link in sharing information and working collaboratively with an external case manager to help the patient achieve the highest level of function possible," she adds.
Creating a plan of care for a catastrophically injured patient is a little like creating a patchwork quilt - you gather up scraps from a lot of different places and stitch it together, says Jolynne "Jo" Carter, BSN, RN, CCM.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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