By Jeni Miller
While healthcare is ever-changing, the practice of making referrals across the continuum of care evolves along with it. Over the last three years, as hospitals have been full and transitions of care have been made in haste, ensuring quality transitions to home health and hospice has become even more important.
Thankfully, technology has helped ease the burden.
“Things are changing every year with Medicare, Medicaid, and insurance plans,” says Andrea Devoti, MSN, MBA, RN, CHCE, NAHC, executive vice president of the National Association of Home Health & Hospice. “But I think the biggest thing that’s changed since I worked on the steering committee for the American Case Management Association’s Transitions of Care Standards initially has been that more health systems, cooperatives, and communities have integrated computer systems. The internet environment, whether it’s part of a system that uses an integrated computer system or not, has facilitated a lot of information and communication.”
The key to helping create smooth transitions in care is communication, Devoti notes. But not just any communication will do. When case managers seek information to transfer a patient into home health or hospice, it is important for the patient to carry with them as much detail about their condition and care as possible.
“Whether it is verbal or written or in the computer system, we need to ensure that those coming into their home or a family’s home for care have something more than just a name on a sheet,” Devoti explains. “We often get patients who simply have nothing with them, no information, and then you can only work from what the patient can tell you or what their family can share — and that may only be one side of the story.”
When a patient comes in with little information, it is up to the nurse to investigate. Sometimes, they can find out more to provide the best possible care — or not.
“All of us sometimes get so stressed and involved, and perhaps we may have given a great verbal report, but it doesn’t always follow the patient out to the home,” Devoti says. “The best way to make it work is to use the system that is in place — and then the information is only as good as what’s input into the system. It doesn’t have to be the greatest novella — just a documentation of what the nurse or case manager is seeing and how the patient is doing. It’s helpful to know when their current problem started and who is following them. If the patient has a difficult family member, or even a member of their family that is doing a stellar job in caring for them, we need to know that, too.”
Problems that arise from lack of information are more than just mere inconveniences, of course. The author of a study on care transitions noted, “Transitions of care are becoming recognized as an important area for improvement in healthcare quality and patient safety. Yet there remains consistent evidence from multiple studies in varied settings of failures to complete safe, effective handoffs from one location of care to the next. Major lapses include absent or limited clinical information and care plan content, plus errors related to medications. There are identifiable problems with half or more of the transitions that occur between care settings, and adverse consequences occur in 15% to 25% of patients. Undoubtedly, these lapses contribute to the rates of rehospitalization in post-acute care, which affect 20% to 30% of patients within 60 days after hospital discharge.”1
As more hospitals merge and systems expand, it is becoming more common to seek integrated computer systems, both in hospitals and home care settings. Taking the time for training to use these systems to their fullest potential can help ease care transitions.
Working as a team in the hospital also can ensure the right information makes it into the patient’s record at the right time.
“We truly need to have communication from the caregivers that saw the patient last, if possible,” Devoti says. “That is the ideal, but I know that in this day and age, and in this nursing shortage, that can be tough to do. However, even secure texting will do. That way, we can be sure that at the very least we have a record of their medications for medication management. That is so important [for home care] because sometimes a patient may get home and they have 15 medications in a shoebox in their closet, and home care needs to know what is current. Further, sometimes the community physicians had no idea their patient was even in the hospital, so it’s helpful to have that in the system.”
What it comes down to is that even given the best intentions, healthcare providers cannot always rely solely on the patient and family to share accurate information. Technology can fill this gap.
Devoti notes there may be a tendency for older patients to hold back information on their own condition or well-being, seemingly out of respect for their healthcare providers. This is yet another area where objective information can help.
“Some older people have been raised that you just say ‘yes’ to the nurse or doctor,” Devoti says. “When given an instruction, they’ll say, ‘OK, sure, I’ll do that.’ My own mother is 93 years old, and if I don’t go with her to the doctor, she will likely still give that ‘white jacket answer’ and tell the doctor that she is fine, even when there is more to the story.”
Case managers can use the available technology to fill in pertinent information that will follow the patient to home care or hospice for an easier and safer transition. Technology also can be useful to case managers who use electronic sourcing to make appropriate arrangements for patients. If information is accurate and complete, they can put the patient out to the network to place them for home care services.
As in nearly every sector of healthcare, the aftereffects of COVID-19 have meant shortages in staff, which has caused a slowdown in discharging patients.
“For case managers, they should be aware that one of the biggest [changes] is that some places are struggling to get nurses and therapists, and it is sometimes difficult for people to be seen that day or the next day,” Devoti explains. “More agencies are saying that they can’t accept a patient if the physician wants them to be seen that day or the next because they just don’t have the staff, or it would violate the [Medicare] Conditions of Participation.”
Other staffing changes include the rise of remote workers. There are few people working in home health company offices, Devoti notes. Even the intake staff for many companies works remotely.
Similarly, remote care also has been more popular since the pandemic began, although in-home follow-up visit rates are returning to normal.
“In-home care and hospice many times had been doing video visits because a number [of patients] didn’t want us coming into their house,” Devoti recalls. “With physician permission, we were able to just check in and do a video visit and, if possible, get vital signs, see the wound, see the medications to ensure they got them from the pharmacy. We continue to do some of that, and in hospice also we do some video visits to check in when families are hesitant to have people come into the home.”
Even when busy, case managers do well to adhere to specific standards to ensure a seamless transition and the best possible health outcome for the patient.
The fourth standard of care shared by Transitions of Care/ACMA reminds case managers “Processes are in place to support the development of an ongoing care management plan, created with input from the patient, primary caregiver, and family. This care plan should be accessible to all care managers and remain with the patient’s regular ambulatory care provider for continuity.”2
“If care across the continuum is not well-communicated and documented, then it is doing a disservice to the patient, who needs to be at the center of the care plan,” Devoti says. “Case managers need to talk to the family and the patient as the centerpieces of the plan.”
Devoti recommends if case managers do not yet have a copy of the Transition of Care standards, they should strive to meet the criteria.
“It is such a clear guideline on best practices, and these Transition of Care standards were really set up for departments to adopt and bring in so that case managers themselves can learn and apply these best practices,” Devoti notes. “I think so many of us are wearing so many hats and we’re running on a treadmill, so many may not have seen or tried to implement these standards. It’s not that they don’t want to, but they don’t always have the time or resources to make it happen. But it’s so important because it helps to best take care of the patient and their family.”
Case managers can set patients and families up for success by understanding — and conveying — what home health care is, and what it is not. Unfortunately, there often is misunderstanding among patients and families that can lead to disappointment.
“So many patients go home and think that a private nurse is going to be there by their side 24/7, and that’s just not it,” Devoti says. “It may be that the discharge planners and case managers need to make it clear and paint a more realistic picture for them, and certainly not allow the patient to believe that they are going to have 24/7 care, since that’s not typically how home care works.”
Devoti recommends telling patients they will receive “intermittent care” from a nurse and/or other disciplines according to their needs.
“Most patients get two or three visits per week by a skilled nurse or therapist, and those visits are often about 45 minutes to an hour,” Devoti says. “If the patient will need assistance with baths or personal care, they may have a few visits to teach them how to care for themselves in the home. That person will assist, but there is no guarantee that someone is coming to do this care — not to mention housekeeping and shopping — and that’s what most people think they’re getting.”
Patients also often come to expect their private duty home care will be covered by Medicare. When it is not, they become upset.
“It happens often,” Devoti explains. “Some of it isn’t either side’s fault. In general, many Americans don’t understand healthcare coverage. Then, when Medicare or managed care may have a limited number of visits, based on a physician and nurse assessment, it can be even more confusing. For example, a total knee replacement may result in one number of visits, and a total hip replacement is a different number of visits. Since it is always changing anyway, it may be most helpful for case managers to just say, if they aren’t sure, that the patient will just have to ask when they get there whether or not their care is covered by their policy.”
REFERENCES
- Boling PA. Care transitions and home health care. Clin Geriatr Med 2009;25:135-48, viii.
- Transitions of Care. Transitions of Care standard 4.0.
While healthcare is ever-changing, the practice of making referrals across the continuum of care evolves along with it. Over the last three years, as hospitals have been full and transitions of care have been made in haste, ensuring quality transitions to home health and hospice has become even more important. Thankfully, technology has helped ease the burden.
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