By Melinda Young
Health systems continue to address social determinants of health in their post-discharge care for patients. Case managers are on the forefront of this trend.
“One of the new solutions and strategies that exist is the community health worker — a master’s-prepared social worker and complex care nurse navigator in the acute care setting,” says Yvette Campbell, MSN, RN-BC, CCM, director of case management and transfer center at St. Mary’s Health Care System in Athens, GA. “Community health workers work in conjunction with case management departments and care managers to provide post-acute ongoing care needs.”
Community health workers call patients in post-acute settings to give information and access to community resources. They address patients’ issues with transportation, food insecurity, and affordable housing. For instance, community health workers can provide post-acute follow-up contact to address access to community resources, including transportation to doctors’ appointments.
“They can address behavioral health services, utility payment assistance, application for Medicaid assistance, and any other federal/state/local agency community assistance for underserved members of the communities,” Campbell explains.
Partnering with the case management department, they can focus on post-acute chronic disease management and patient education, particularly for high-risk patients.
As a case manager for about 25 years, Campbell has seen how payers, including managed care, have helped drive the focus on social determinants of health. “Our healthcare delivery systems have changed and evolved over the years,” she says. “I’ve seen things come full circle, and it affords me the opportunity to anticipate when and how changes are going to occur.”
Case managers, nurses, and social workers are at the forefront of transitional care linkages for people in the community. Trends suggest future emphasis on more transitional care options, shorter hospital stays, and post-acute transitional care options.
“Transitional care is very important, and our case managers and social workers are at the forefront of ensuring patients have adequate transitional care options,” Campbell says.
One of case managers’ biggest challenges in care transitions is limited post-acute care access in some rural and local areas. For example, there are limited primary care and specialist providers available for patients transitioning from a hospital to the community. This makes securing a follow-up appointment particularly challenging from a case management perspective.
Other post-acute services also are in limited supply. These include sub-acute skilled nursing facilities within a patient’s payer network, home health resources, and life-sustaining ambulatory care treatment resources, such as dialysis and outpatient clinic infusion services for completing IV antibiotic therapies. When these services are available, they can shorten acute care stays for uninsured and underinsured citizens in a community, Campbell says. Patients who live in rural communities also face limited access to transitional care options.
Patients also have limited knowledge of care self-management. “Poor health literacy for the consumers and caregivers limits adherence to self-management of chronic diseases,” Campbell says. “Poor health literacy is defined as an inability of consumers or caregivers to comprehend health information and/or apply the necessary skills that could mitigate exacerbations of illness.”
Since the COVID-19 pandemic began, case managers and other healthcare professionals have learned more about engaging in creative collaborations and using patient/provider portal platforms.
“The development of relevant metrics, such as the number of patient engagement sessions, percentage of hospital all-cause readmissions, and adherence to prescription refill schedules, could measure success with ongoing high-touch patient/provider interactions,” Campbell says.
For example, patient portal platforms are even more prevalent with insurers, pharmacies, providers, and acute care facilities than a decade ago.
“This strategy creates avenues for patients and providers to engage about healthcare and chronic disease management outcomes, scheduling of follow-up appointments, and engagement with service line, ambulatory case managers in various communities,” Campbell explains.
Health systems continue to address social determinants of health in their post-discharge care for patients. Case managers are on the forefront of this trend.
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