Case management starts at ICU, goes through discharge
Seriously injured patients require long-term care
Anna Gibson, RN, CDMS, a case manager specializing in catastrophic injuries and rehabilitation, typically gets a call when a catastrophically injured worker has just arrived at an acute care hospital and has been admitted to the intensive care unit.
Gibson, a network manager for Paradigm Management Services, manages the care of catastrophically injured patients throughout the state of Georgia.
"I go to the trauma center and start working with the social workers and case managers there, trying to get a handle on the severity and degree of injury," Gibson says.
She works with the hospital case managers to arrange for the family to visit rehabilitation facilities that may be a good discharge destination for the patient.
"We always include the family in decisions. If we are recommending a facility that's 100 miles from their home, they have a lot of things to pull together as well," she says.
When a patient is almost ready to be transferred from an acute care facility to a rehabilitation center, Gibson arranges for the case manager from the receiving facility to either go on site to evaluate the patient or conduct a telephone interview to ensure that the patient is an appropriate admission.
"We all start working on a discharge date. Everybody has to be flexible. The patient has to be medically stable to be transferred, so it's sometimes hard to predict a specific date," she says.
Whenever possible, she meets the family at the new facility on the day of admission and helps them settle in.
"I'm back the next day or the following day, reviewing the evaluations from the treatment team. During that time, I communicate with the receiving facility's case manager about family dynamics, any red flags I have noticed, and other information that may be helpful," she says.
Gibson attends the weekly team conferences and works closely with the treating physician, physical therapist, occupational therapist, respiratory therapist, psychologist, case manager, and representatives from nursing and nutrition.
During the first team conference, the team discusses the probable length of stay, what can be accomplished during the stay, what will be the discharge setting, what it takes for a safe discharge, and how to maximize the patient's independence in a discharge setting.
Gibson visits the patient's home and conducts an extensive assessment to determine if it is an appropriate place to consider for discharge and establish what modifications will be necessary to accommodate the patient after discharge.
She assesses the home for needed home modifications and works with the insurance carrier to get the modifications started.
She considers what resources the family has and what is available in the local community.
When the patient is approaching discharge from the center of excellence, Gibson coordinates with the center's case manager to make sure that the discharge needs are met.
"It may mean getting home health established and making sure equipment is ordered and that loaner equipment is available," she says.
For instance, custom wheelchairs take six to eight weeks to arrive, and they usually aren't ordered until shortly before discharge. The patient needs to leave in a loaner chair.
Many spinal cord patients are discharged from the rehab center to a day program. If necessary, Gibson finds a temporary living situation for patients who will be in a day program.
Many times, insurers don't approve home modifications until nine to 12 months after the injury when the patient has stabilized and the modifications are necessary to meet his or her long-term needs.
In that case, Gibson often has to find a temporary living situation for the patient.
"I've done everything from renting an apartment to finding an extended-stay hotel room. Sometimes the patient can go into the home setting but can't get the wheelchair into the bathroom. We set up a portable toilet and a private area so the staff can give the patient a bed bath," she says.
Gibson generally stays involved with a case between one to two years.
"I follow them through all their acute therapies until they have a maintenance plan in place and their physician visits are for routine evaluation and follow-ups. By then, the patients have been so well educated and empowered that they want to take over," she says.
Anna Gibson, RN, CDMS, a case manager specializing in catastrophic injuries and rehabilitation, typically gets a call when a catastrophically injured worker has just arrived at an acute care hospital and has been admitted to the intensive care unit.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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