Daily schedule keeps CMs working consistently
To help all 10 care managers work efficiently and consistently, case management leaders at Grady Health System in Atlanta have developed a daily schedule based on priority action items.
Care managers at Grady follow this daily routine to provide case management for an entire patient group:
1. Obtain shift report.
2. Identify new admissions.
3. Identify patients scheduled for discharge.
4. Identify patients who are high-risk for discharge planning.
5. Make a list of patients to be seen on discharge rounds, admission rounds, and treatment rounds (prioritize by patients who meet high risk for discharge planning criteria).
6. Make discharge rounds (see patients at high risk for discharge planning first):
* Review patient's medication administration route.
* Identify those medications that will be home discharge medications.
* Give patient education cards on the home medications identified to patient or significant other. If patient/significant other can't read, seek alternative patient education method.
* Assess patient's understanding of patient medication cards.
* Complete episode of care for discharge phase.
* Ensure all discharge planning activities have been met, as evidenced by:
-- patient's understanding of self-administration of home medications;
-- patient's ability to access hospital/
community resources, such as appropriate shelter;
-- patient's understanding of instructions regarding clinic appointments;
-- patient's ability to perform return demonstration on technical skills and use of supplies and equipment.
* Document actions taken, patient response, and follow-up care.
7. Make admission rounds (see patients high-risk for discharge planning first):
* Introduce self.
* Give card and handout on the Care Manager Program.
* Explain the Care Manager Program.
* Obtain correct telephone number.
* Assess where patient will go upon discharge.
* Assess the need for transportation.
* Assess patient knowledge level on reason for admit or admitting diagnosis.
* Assess need for diabetic education, dietitian education, social worker, or other referral.
* Assess patient's economic resources and health insurance.
* Assess patient's need for appropriate outpatient Grady card.
* Assess patient's support system.
* Assess patient's need for assistance with activities of daily living.
* Initiate the appropriate consults/referrals for discharge planning.
* Give patient education material on admitting diagnosis. If patient can't read, seek alternative patient education method.
* Document all actions taken, patient response, and follow-up care.
* Assess patient's understanding of patient education material.
* Complete episode-of-care checklist for admission phase.
8. Identify patients in treatment phase.
* Make rounds on patients with the following:
-- indwelling Foley catheters;
-- total parenteral nutrition administration;
-- blood administration;
-- enteral tube feeding;
-- multiple decubiti;
-- active do not resuscitate (DNR) order;
-- surgical wound management;
-- long-term antibiotic therapy;
-- long-term anticoagulant therapy;
-- isolation for pulmonary tuberculosis;
-- restraint management;
-- pain management;
-- ostomy management;
-- awaiting nursing home placement.
* Review medical records of patients in treatment phase (make patients high-risk for discharge planning a priority).
* Complete episode of care checklist for treatment phase.
* Note all variances. Meet with charge RN/assistant clinical manager and report findings. Together with charge RN/assistant clinical manager, take necessary corrective actions.
* Work with other disciplines, such as utilization review, social services, rehabilitation therapy, physical therapy, and dietary, as needed.
9. Monitor upkeep of discharge tracking board.
10. Record variances on variance reporting tool.
11. Follow up on resolutions of problem identified.
12. If assigned to any subcommittees, such as utilization review (UR)/risk management, standards of care, audit, continuing education, complete those tasks.
13. Complete all other duties as they are due, such as monthly reports, rounds with CNS, conference with clinical manager.
14. Make post-discharge patient contact as needed or requested for follow-up return to clinic.
15. Plan and implement/coordinate inservices to staff for corrective actions on problems identified.
Inservices should include, but not be limited to, the following:
* inadequate, or omission of, required documentation;
* Centers for Disease Control and Prevention/Grady Health System definitions and prevention of the following nosocomial infections:
-- urinary tract infection;
-- surgical wounds;
-- venous bacteremia;
-- upper-respiratory infection;
* identifying adverse drug reaction;
* total parenteral nutrition management;
* blood administration;
* enteral tube feeding protocol;
* update on antibiotic therapy;
* restraint management policy/procedure;
* patient education for pulmonary tuberculosis;
* pain management principles;
* anticoagulant therapy -- patient education;
* understanding DRGs. *
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