Dedicated CM coordinates discharges for patients
April 1, 2012 4 minutes read
Dedicated CM coordinates discharges for patients
Position frees up CMs, SWs time
At Montefiore Medical Center in the Bronx, NY, a complex care case manager coordinates appropriate post-discharge options for uninsured and under-insured patients who are likely to need complex care after discharge.
"We're seeing more patients with complex needs, especially those who are uninsured or underinsured, and who require too much care to be discharged to home. These patients do not fit into traditional niches, making it difficult and time consuming to find appropriate placement in the community. Having someone who is dedicated to finding and coordinating post-discharge care for the difficult-to-place patients frees up the case managers and social workers to concentrate on moving other, less complex patients through the system," says M. Alexander Alvarez, RN, director of the care management resource unit at the 1,491-bed medical center, located in one of the poorest counties in the country.
Anne Meara, RN, MBA, assistant vice president for network care management for Montefiore Medical Center adds that the hospital is seeing an increasing number of patients with complex needs, especially those who are uninsured and underinsured and who require too much care to safely be discharged to home. "Each case involves a lot of complex issues whether it's people with developmental disabilities who can no longer be taken care of by their family, patients with immigration status issues, housing issues, complex clinical needs, or any combination. It's the role of the complex care case manager to be an expert on all the resources in the community and help the patient get access," Meara says.
The social workers and case managers refer cases that need a focused level of intervention to the complex care case manager, who began work in December, 2011. Before that, Alvarez and nurse and social work managers worked on these cases along with their other duties. Recently, the complex care case manager was coordinating post-acute care for 43 patients.
When the complex care case manager receives a referral, she gets the patient, the family and/or caregivers and the treatment team together to identify an appropriate venue of care, what assistance programs the patient might qualify for, and what documents the patient needs to establish eligibility.
To meet the needs of unstably housed and homeless patients who require post-acute care in the community, the hospital has entered into a contract with Comunilife, a non-profit, community-based organization that provides a broad array of services including housing. The complex care case manager collaborates with Comunilife to identify post-discharge options for homeless patients with multiple problems who are likely to have complex issues after discharge. For instance, the patients may need IV therapy or dressing changes. The patient is discharged to a respite care bed in a Comunilife facility in the community.
"The organization provides a safe environment where homeless patients can go and receive home care and other services," Meara says. The partnership between Montefiore and Comunilife evolved from the need to provide a safe post-acute environment for medically stable patients whose housing situation was a barrier to receiving needed, ongoing care in the community, she says. Comunilife has case management services that work with patients on long-term plans, such as finding permanent housing.
For instance, Montefiore worked with Comunilife to find services for one patient who had medical issues that required post-acute care. Returning to her pre-hospitalization housing situation with a family member was not an option at the time of discharge. "Without the partnership with Comunilife, this patient would have been in the hospital for an extended period of time while alternate living arrangements were explored," Meara says. The patient was discharged to Comunilife where she received home care services while a case manager worked with her to arrange permanent housing in an assisted living center, where she received supportive services. The patient has not been readmitted to the hospital.
Alvarez adds that the hospital is the safety net for people with psycho-social needs as well as the complex medically ill patients. For instance, a family dropped off an autistic teenager in the emergency department when his behavior could no longer be managed at home. "He wasn't physically ill but he didn't have a place to go. A lot of people think that the hospital is a safe place and that it's OK for people to stay here for a long time," he says. The young man stayed in the hospital several months while the hospital staff worked with the family and community and governmental organizations to determine the most appropriate long-term placement. While the young man was hospitalized, a multidisciplinary team collaborated to formulate a plan to deal with behavioral issues arising on the unit. One outcome was that arrangements were made his for him to go to the rehabilitation department every day and exercise to work off energy. His social worker accompanied the boy's mother on a tour of the residential facility that was identified as an appropriate place for the boy. "Often we go way beyond the medical boundaries when people have a lot of complex issues," Alvarez adds.
The hospital has assembled a complex case advisory team to review post-discharge issues and come up with a plan to present to the hospital's senior leadership.
The complex case advisory team includes a physician from the office of the medical director, and representatives from nursing, bioethics, legal, risk management, social work, and customer service. The committee meets every two weeks and invites members of the treatment team to bring in cases for review.
Source
- Anne Meara, RN, MBA, Assistant Vice President for Network Care Management, Montefiore Medical Center, Bronx, NY. Email: [email protected].
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