Discharge Planning Advisor
Referrals ensure continuum of care
Packets outline available support services
When it comes to referring acute care patients to disease-specific education programs, the referral process at Akron (OH) General Medical Center is simple. Patients admitted to the hospital with a chronic disease such as asthma, diabetes, or congestive heart failure are given a teaching packet that has a list of support services. A nurse goes over the information with all but the asthma patients who receive the teaching from the respiratory therapist.
In all cases, the educator strongly encourages them to attend an outpatient class, but does not make a formal referral, says Billie M. Foley, RN, MSEd, patient education coordinator at the medical center.
Patients who are admitted to Jackson Memorial Hospital in Miami with a chronic disease also receive a standard educational package. However, the materials are considered a "starter" to education, explains Peggy McLoughlin, RN, JD, chronic disease manager at the health care facility. For further education, the inpatient case manager enrolls the patient in a group class, such as diabetes self-management, and refers the patient to the disease state case manager.
Classes are available at primary care sites in the north and south ends of the county and at the hospital’s main campus with two sites offering education in Spanish as well as English.
"Once a patient is referred to our disease management program, the disease state case manager does a risk screening of the patient and assigns the patient to either a low, medium, or high-risk category. The criteria vary by disease, but the main categories are clinical, adherence, and psychosocial risk factors," says McLoughlin. The overall risk level of the patient governs the frequency of interactions with the case manager. High-risk patients receive intensive one-on-one education from the disease state case manager.
An example of the process is as follows:
- Patient admitted to hospital with a diagnosis of diabetes.
- Patient placed on a clinical pathway.
- Patient followed in-house by inpatient case manager.
- Patient referred to the appropriate disease state case manager who follows the patient after discharge.
- Patient screened for risk level at primary care site.
- Patient’s level of risk determines the frequency of interactions with the disease state case manager.
"The goal of the disease state case manager is to work with the primary care provider to maximize medical therapy and provide the patient with the skills necessary for self-management of the disease," explains McLoughlin. As the patient develops the skills to manage the disease on his or her own, the risk level is reassessed.
When a person is admitted to Grant/Riverside Methodist Hospitals with a diagnosis of diabetes, the patient receives an automatic consult with a diabetes educator. If a patient has asthma and has a new breathing treatment prescribed by the physician, a respiratory therapist comes to teach. Similarly, cardiac rehab provides an educator for heart patients. In each case, the educator talks to the patient about the benefits and support of an educational outpatient program pertinent to management of their chronic disease. If the patient is interested, a referral is made, says BJ Hansen, BSN, patient education coordinator at the health care system in Columbus, OH.
Because many of the heart patients are from outside the Columbus area, a list of rehab programs throughout the state of Ohio is maintained. "We have a list of all the cardiac rehab programs in the state of Ohio we give to the patient, and we try to get them to a cardiac rehab program in their area if they are willing to go," says Hansen.
Within their own system, they have a heart disease management clinic and a Coumadin clinic for heart patients. For asthma management, there is an asthma clinic/pulmonary rehab program, and for diabetes patients, outpatient classes are available with a case managed program available for HMO members.
Specialists automatically visit patients with heart problems or a diabetes diagnosis when they are admitted to Provena Mercy Center in Aurora, IL. During the education session, cardiac rehab nurses teach the heart patient and explain the health care systems’ cardiac rehab program. They set up a time for the patient to begin the program after discharge, explains Rita Smith, MSN, RN, education coordinator. "For patients with diabetes, the dietitian sees the patient and refers them to the diabetes support group that meets once a month. Also, they are given my name and number so they may come in as an outpatient for further education sessions on managing their diabetes at home," says Smith.
To make sure asthma or diabetes patients coming to the emergency department at Jackson Memorial Hospital don’t slip through the cracks, case managers intercept them. "They initiate education and give the patient a starter’ education packet. They will also determine where the patient receives their primary care, and make an appointment to the appropriate class," says McLoughlin. The names of the patients are forwarded to the disease state managers who conduct the classes and follow the patients in the primary care centers, she explains.
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