Success in today’s healthcare arena requires a collaborative effort from the entire clinical team, says Cheri Lattimer, RN, BSN, executive director of the Case Management Society of America (CMSA).
“If a team approach isn’t in place, we see issues with medication errors, lack of follow-up visits, poor adherence to the treatment plan, all of which contribute to some type of adverse incident,” Lattimer says.
It’s not just the responsibility of the case manager to support good transitions, reduce avoidable readmissions, and improve patient safety and quality care during and after the hospital stay, Lattimer points out.
“It’s the responsibility of the entire interdisciplinary team: physicians, pharmacists, therapists, social workers, case managers, nurses, and allied health professionals. Hospital staff have got to stop functioning in silos and work together to ensure that patients get the care they need, improve patient safety and quality, support a good transition, and assist with reducing avoidable readmissions,” Lattimer says.
One key to success is optimizing the healthcare team, says Patrice Sminkey, RN, chief executive officer for the Commission for Case Management Certification.
Look at the roles and responsibilities of each team member and make sure each discipline is working at the top of its license, she adds.
“Care coordination takes a multidisciplinary approach involving an entire department — case managers, social workers, and with the addition of non-clinical extenders who can free up the licensed staff to do what they are trained to do,” she says.
Case managers and social workers should be working at the top of their licenses and using their skills and education to do the jobs they were trained to do, Lattimer says. “They shouldn’t be making sure patients have follow-up appointment and that durable medical equipment was delivered. Those tasks don’t require the expertise of licensed staff,” she adds.
When she works with hospitals across the country, Toni Cesta, RN, PhD, FAAN, partner and consultant in Dallas-based Case Management Concepts, observes that case managers are spending a lot of time on jobs that don’t require their expertise and training.
“It’s not practical to pay a nurse to sit over a fax machine or stay on the phone to order a walker. We recommend that in addition to making sure caseloads are appropriate, case management departments provide clerical support for the case managers. Faxing, setting up equipment deliveries, and other clerical tasks are not a good use of a case manager’s time,” she says.
Case managers don’t have the time to follow up with every patient after discharge, Lattimer points out. “This is where understanding patients’ acuity and their needs is absolutely key. For most patients, follow-up phone calls can be assigned to an extender who can ask basic questions and refer the patients to a case manager if they need further follow up,” she says.
Follow-up calls also can be done by volunteers if they have a specific set of questions and are trained to know when to refer the patient to a nurse or social worker, Kizziar says.
She suggests developing a set of 10 or so questions that can be answered “yes” or “no.” Depending on the answer, the computer will direct the volunteer to the next question.
It’s not just the responsibility of the case manager to support good transitions, reduce avoidable readmissions, and improve patient safety and quality care during and after the hospital stay.
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