By Melinda Young
Case managers are well-positioned to help prevent rehospitalization of sepsis survivors by ensuring a smooth transition to post-acute care services. They can provide follow-up to ensure patients are receiving the home health services, therapies, and primary care visits they need.
“Post-discharge phone calls can be helpful,” says Hallie C. Prescott, MD, MSc, an associate professor at the University of Michigan Department of Medicine. “They can say, ‘We just wanted to follow up and make sure everything is going OK and you didn’t have any questions.’ The more of these things you can do, the better it is for the patient.”
Case managers also can educate patients about their disease and recovery experience after they return home. “I would start with making sure patients know they have sepsis,” says Kathryn Bowles, PhD, RN, FAAN, FACMI, a professor of nursing and van Ameringen chair in nursing excellence at the University of Pennsylvania School of Nursing.
Often, clinicians will keep things simple and not use the word “sepsis.” They may say the patient contracted a bad infection or bloodstream infection.
“Increased awareness is important because it’s part of convincing them that this is not just a urinary tract infection,” Bowles explains. “Their immune system had an overwhelming response to this infection, which impacted their kidneys and heart, and their care needs to continue after their hospital stay.”
Prescott and Bowles gave these suggestions for how to improve post-acute sepsis care:
• Improve discharge education. Sepsis is a term that patients often do not understand, even if they were hospitalized for it.
“People who had sepsis are at risk of being hospitalized again for it,” Prescott says. “People with sepsis may feel achy and confused. There needs to be better education about what sepsis is, its signs and symptoms, and the things we can do to reduce our risk for sepsis, which includes vaccination.”
For example, discharge coordinators can emphasize the need for sepsis survivors to stay up to date on their influenza, COVID-19, and pneumococcal vaccinations.
Physicians, nurses, and case managers play a role in educating sepsis patients. “As a nurse, I’ve always taught and thought patient education was the role of the bedside nurse,” Bowles says. “But it’s all hands on deck, and case managers have a role.”
Discharge education could reinforce the need for home health services. To prevent patients from dismissing this help, case managers could emphasize that someone will need to monitor the patient and help them regain their strength, manage their medications, and watch for signs and symptoms of recurrence.
A case manager might say, “We’ll get you back to pre-hospital conditions, and nurses will come into your home to examine you and make sure your lungs are clear and medications are in order,” Bowles suggests. “We find that patients may not understand what home health services are. When you mention them, they may think their family caregiver could do that.”
While patients imagine home healthcare is about activities of daily living, they need to know home health aide services are separate from home health services provided by skilled nurses.
“They need a skilled professional to assess their condition and communicate to their doctor if they see signs and symptoms of trouble,” Bowles says. “The sooner you catch it, the higher the success rate of treating it.” This is why there is a big push in acute care to catch and treat sepsis quickly because the response is rapid.
Case managers could use material from the National Sepsis Alliance, including online videos and a stoplight tool that could be given to patients to show them which symptoms to watch for and when to call for help.1 The CDC’s educational campaign, called Get Ahead of Sepsis, covers the common signs and symptoms.2
• Provide early follow-up after discharge. “When people leave the hospital for sepsis, a lot of times they go home and they’re overwhelmed,” Prescott says. “There’s a need to better support people in this transition and in the immediate hospital aftermath.”
Too often, sepsis patients are given paperwork with instructions and told to contact their primary care provider. This is inadequate. “A lot of times, they don’t have a scheduled follow-up appointment after discharge,” Prescott says. “It’s a gap, and some patients are better equipped than others to go on and get that appointment.”
It is critical for sepsis patients to obtain follow-up care. Patients need a point person’s phone number so they can ask questions. Post-discharge phone calls from case managers or other nurses would be helpful for the higher-risk patients. For example, case managers could help patients schedule primary care visits and answer their questions immediately.
Communication from the hospital to post-acute care providers also is a huge role that case managers can complete, Bowles says. “When they prepare for referral to home health services, they can clearly mark on the referral that this is a sepsis survivor,” she explains. “We have seen that referral documents may not use that word, and the discharge summary may not have sepsis on it if the physician marks sepsis as resolved, which it often is.”
The goal is to ensure post-acute providers know about the patient’s sepsis diagnosis and pay close attention to the patient in the first week after discharge.
“Among patients who are hospitalized, within 30 days of discharge, 32% of those readmissions occur within the first seven days,” Bowles notes.
• Encourage patients to follow through on post-acute appointments. Case managers can reinforce the need for patients to follow up on physical therapy, occupational therapy, home healthcare, and any other outpatient appointments their physician recommended.
“Make sure they understand what home care is,” Bowles says. “Tell them the importance of finishing any antibiotics they’re on. If they stop taking their medication, they could get a reinfection.”
Patients need to know what to expect in their recovery, including fatigue, weakness, and brain fog. Visiting their post-acute providers and receiving in-home health as referred by their physician can help them with this recovery, Bowles says.
REFERENCES
- Sepsis Alliance. What is sepsis. Updated Jan. 13, 2022.
- Centers for Disease Control and Prevention. Get Ahead of Sepsis — Know the Risks. Spot the Signs. Act Fast. Last reviewed Sept. 11, 2023.
Case managers are well-positioned to help prevent rehospitalization of sepsis survivors by ensuring a smooth transition to post-acute care services. They can provide follow-up to ensure patients are receiving the home health services, therapies, and primary care visits they need.
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