Start to get your facility ready to use the CARE tool
Develop relationships with post-acute providers
It will be several years before the Centers for Medi-care & Medicaid Services (CMS) will require hospitals to use the Continuity Assessment Record and Evaluation (CARE) tool, but hospital case managers can start now to prepare for its implementation and to give CMS feedback on the tool and its use in various settings.
Check out the CARE instrument on the Internet at www.pacdemo.rti.org and compare the information it tracks with what you are currently providing to post-acute facilities, suggests Jackie Birmingham, RN, BSN, MS, CMAC, vice president of professional services at Curaspan Health Group in Newton, MA. (Editor's note: You may submit your comments by visiting the demonstration web site and clicking on "contact us.")
"Now is a good time for case managers to look at what they are doing in discharge planning and to get ready to take advantage of the CARE tool when it is implemented," Birmingham says.
NTOCC to improve quality among health care settings Concerned about the gaps in care that occur between health care settings, 13 organizations in the health care field joined together in 2006 to address the problem. Currently, 29 organizations participate in the effort to improve communication and coordination between health care professionals, patients, and caregivers as patients transition through the health care continuum. The organization is chaired and coordinated by the Case Management Society of America. The coalition recently launched a web site that includes tools and resources that health care providers can use to help ensure a smooth transition for their patients, including a list of recommended information about a patient’s medication, a transitions of care checklist, a medication reconciliation form, and a guidebook for implementing and evaluating a transition-of-care plan. For more information, visit the web site at www.ntocc.org. |
Take the opportunity to work even more closely with your post-acute providers and learn what they deal with on a day-to-basis. Find out what they need from you and let them know what you need from them, Birmingham suggests.
"The CARE tool will ensure consistency across the levels of care so that the case managers in one setting will better understand what the case managers in another setting are telling them. This represents a good opportunity to create a closer working relationship between hospitals and providers," Birmingham says.
To help new and inexperienced case managers in the hospital understand what it will be like for patients when they are transferred to another level of care, set a goal to have them spend a day at another facility to learn what happens at that level of care, Birmingham suggests.
To ensure an easy transition, start looking at what you are already collecting electronically and how it corresponds with what's on the CARE tool, suggests Diane E. Holland, PhD, RN, clinical nurse researcher, department of nursing at the Mayo Clinic.
Holland is working with a student to map the items on the CARE tool to find out what is already available in her hospital's electronic record.
Don't feel overwhelmed when you see the instrument on the web site, cautions Birmingham.
The Internet version is a paper-based tool that contains both the core and supplemental items. When it's available on the secure web site, it will be as easy to use as the current web-enabled shopping networks or travel reservation systems, Birmingham says.
"The paper form makes it look unwieldy and long. Imagine it in the electronic environment when information can be pulled in electronically and only the part pertinent to that particular patient is pulled up," she says.
"The content of the CARE tool is what is important," Birmingham adds. "The needs of the patient, what to assess and when to assess specific characteristics will make the function of discharge planning more reliable and produce better outcomes for patients."
It will be several years before the Centers for Medi-care & Medicaid Services (CMS) will require hospitals to use the Continuity Assessment Record and Evaluation (CARE) tool, but hospital case managers can start now to prepare for its implementation and to give CMS feedback on the tool and its use in various settings.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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