Choose post-acute settings carefully
Involve patient, family in options
Historically, clinicians have always done for the patient and not with the patient, a practice that has to change in order to ensure a safe discharge and prevent readmissions, says Cindy Reilly, RN, BSN, vice president of quality and patient safety at Marlborough (MA) Hospital, part of UMass Memorial Healthcare.
"Case managers must involve patients and their families or caregivers in the plan of care from the beginning. We need to start to educate the patient and family about the next step early in the stay and make sure they are comfortable with their expected discharge destination," she says.
Case managers need to ensure that the continuum of care is available to support patients after discharge. Develop strong relationships with local skilled nursing facilities, home health agencies, short-term rehab facilities, and other post-acute providers, Reilly advises.
"Now that post-acute providers are being monitored by the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission, they have a vested interested in preventing readmissions," Reilly says.
Peggy Rossi, BSN, MPA, CCM, a retired hospital case management director who now is a consultant for the Center for Case Management, recommends holding case conferences with families to find out what they really want and involving high-risk patients’ insurers to bridge the continuum of care.
Don’t just send patients with high post-acute needs to a nursing facility. Make sure the facility can take care of the patients and that staff are trained to handle your patient’s specific needs, she adds.
Rossi advises case managers to do their homework on which facilities could meet patient needs. Keep up with the latest state surveys for your local facilities and also visit the facilities in person and take the administrative tour during the day, but go back at night to see what happens when the administration has left. Check out the ambiance, the smells, how the staff interact with patients, and if the patients seem happy.
When Rossi was a case manager she visited all 40 facilities in the Sacramento area twice a year.
When you send queries to post-acute facilities, make sure to send enough information so the facility can determine if the patient would be a good fit. Call ahead to make sure they can take care of patient needs. "If a patient is high risk, even if you have dozens of skilled nursing facilities in your area, it may be that only one or two can care for the patient," she says.
For instance, if a patient has a tracheotomy and needs multiple suctioning, a skilled nursing facility may not be able to fill the need and the patient might be better off with a subacute or long-term acute care hospital (LTACH) stay.
Be familiar with your state administrative code and requirements for skilled nursing facilities. "For instance, the state of California requires one RN on duty for every 99 patients during the day, with care at night provided by LPNs or aides. California requires only 3.25 hours of patient care per day. If patients need more intensive care, they’re going to come back to the hospital," Rossi says.
Make sure all the I’s are dotted and the T’s crossed during the discharge process, Rossi says. For instance, the pharmacy at some nursing home facilities is closed on weekends. If patients are discharged on Friday with no medication available until Monday, they’ll be back in 24 hours.
Instead of handing family members a list of multiple facilities, give them only a few you have determined would be a good fit for the patient. Encourage families to take the formal tour of facilities, but go back at dinner time and observe what is happening. Encourage the family to review the state survey on nursing homes and Medicare’s Nursing Home Compare website in addition to visiting facilities.
"Create the right expectation for families. They may think one facility looks wonderful and have their mind set on it, but that facility may not be able to meet the patient’s needs," she says.
