Care Coordination Best Practices: The Right Care At The Right Time

Care coordination becomes critically important as the acuity of patients increases, and hospitals face financial challenges as a result of readmission penalties, declining reimbursement and higher costs. Care coordination ensures hospitals provide care in the right setting at the right time, and that they achieve clinical outcomes, patient/family engagement in planning, and safe and effective care transitions. For most healthcare organizations, case managers are seen as the guardians of the care progression and discharge plans – and these three essential best practices will help both case managers as well as hospital leaders to deliver the right care at the right time.

Best Practice #1: Hold Daily Interdisciplinary Care Coordination Rounds at the Bedside for All Patients, Including Those in Critical Care Areas

The value of daily transition of care rounds has been repeatedly discussed in current literature. Moving these rounds to the bedside offers the opportunity to establish clear communication with patients and family members. Rounds should typically include the patient’s physician, nurse, case manager and any other disciplines whose interventions contribute to the progression of the patient’s care. Bedside discussions should focus on what is keeping the patient in the Hospital, what has happened in the past 12-24 hours that impacts the transition plan, and what needs to be done in the next 24 hours to remove any barriers. Moving these rounds from hallway to bedside can be difficult for teams who often express concern that involving patients could prolong discussion and make the rounds too lengthy. To address this, caregivers should be coached on ways to keep the rounds on topic, with attention to how the leader can acknowledge the patient’s or family’s concerns while deferring the detailed discussions to another time. Statements like “It sounds as if you have a lot of questions. I will make sure Jane comes back this afternoon so that we have time to go over everything” keep rounds on topic and reassure the patient that their voice is important.

When setting up daily transition rounds, don’t forget to include critical care units. Rounds in these departments often take on a more medical focus, but should be adjusted to include discussion about the patient’s progress and plan of care. Keep in mind that the ICU is a costly setting and that patients are at risk for adverse events and outcomes, making the need for focused care coordination imperative. Because of the complexity of the care provided, patients and families are often confused. Daily care progression rounds provide an excellent forum for summarizing and clarifying the plan, as well as ensuring that best practices are in place for patient safety, sedation and weaning, nutritional support, and early mobilization. For those patients experiencing prolonged stays, rounds should be used to set up complex care meetings with family members, so that they understand the possible outcomes of the patient’s course and can begin to work with case managers or social workers evaluate options. Critical care rounds, when implemented in this way, serve to improve team communication and position everyone to effectively address patient/family questions and concerns.

Best Practice #2: Include Licensed Social Workers and Registered Nurses in Your Case Management Model, and Ensure Consistent Coverage Through the Week and Extending Through the Weekend

Consistent staffing of case managers and social workers is an imperative for hospitals today. While organizations have traditionally considered case management as a weekday operation, where planned and unplanned time off could be easily accommodated by adding to existing case loads, this is no longer true. The need for experienced case management to assess patients and families, coordinate complex services to expedite safe care transitions, address the risk of readmission, and provide post-discharge follow-up requires the specialized expertise of both nurses and social workers. Coverage needs to be maintained for each unit without compromising another by attempting to absorb additional work, and extend through the weekend and Holidays to support the implementation of more complex transition plans.

Best Practice #3: Create a Strong Case Management Presence in the Emergency Department and Other Points of Patient Access to the Organization

Effective care coordination practices begin with the assessment of appropriate care settings and necessity for hospitalization. Incorporating case management nurses and social workers at all access points is the most effective way to collaborate with physicians and other providers to determine the plan of care that best meets the needs of the patient and hospital. Case management oversight should be incorporated into any patient placement process so that bed requests from post-operative and post-procedure recovery areas, the emergency department, and all other direct admission and transfer sources are reviewed. This serves as a mechanism for the assessment of medical necessity and the opportunity to identify appropriate community services to support patients safely and avoid a hospital stay. With the proposed change in requirements by the Centers for Medicare and Medicaid Services calling for discharge plans to be in place for all patients (inpatient, observation, post-procedure), the inclusion of a case management professional at the point of entry will facilitate this initial assessment, offer an opportunity for patient/family discussion, and position the hospital and care team to be more successful in creating and sharing the transition plan.

In conclusion, the changing healthcare landscape has created challenges for hospitals as well as patients and their families. As a result of new and evolving regulations by government and private payers, increased incentives to avoid hospitalization, and penalties for failing to achieve quality and safety metrics, there is clear need for dedicated professionals to coordinate and oversee patient placement and daily care processes. The burden on physicians and clinical staff at the bedside is significant as a result of higher patient acuity, further emphasizing the need for strong care coordination professionals and processes to engage the multidisciplinary team and to ensure that the care provided is safe and effective and meets the needs of the patient, family and payer.