Case managers are expected to ensure seamless, quality, cost-effective patient care across specialties, a difficult task that can be made easier with the use of evidence-based practice (EBP) and interdisciplinary understanding.
"This is an important time for care coordination," stressed Kathy Tynan-McKiernan, MSN, RN, ACM, director of care coordination, Yale-New Haven Hospital, New Haven, CT. "It is the time for knowledgeable, professional nurses who understand how to coordinate and make a plan of care that is successful."
Experience, extensive knowledge and interdisciplinary communication are vital as case managers work together to transition patients through the continuum of care and prevent avoidable rehospitalizations.
Considering the Evidence
No matter your field or area of expertise it is always important to support any claim with evidence. This is especially true in case management, where multiple disciplines are involved in decision making.
Take, for instance, a patient admitted into the hospital with congestive heart failure (CHF).
"The hospital's case manager transitions the individual throughout their stay, who eventually ends up back in the community and ultimately in their own home," she said.
"They will follow certain clinical pathways depending on symptoms and so forth," said Lauren Huber, MA, BSN, RN, COS-C, CCM, head of staff development for Hebrew Hospital Home Community-Based Programs Bronx, NY, who also continues to dually practice clinical case management in the field as well as on the managed care provider side.
Following discharge this CHF patient's care management shifts to an outside case manager, often multiple - on the part of the payer as well as the providers of clinical care in the community. EBP related to homecare is now instrumental in determining and implementing clinical care, as well as including access to appointments, transportation, physical therapy, etc.
"I have a CHF patient who did great when they were in the hospital, but now he is home in his fourth floor walkup in the South Bronx," said Huber. "I want to be able to monitor him and see him three times a week for the first two weeks, so I have to reach out to the insurance company's case manager."
While Huber uses EBP to determine the best course of care, the case manager for the insurance company does the same.
"Based on the standards of practice the insurance company uses for a CHF patient with these particular symptoms the case manager may tell me I can have two visits a week. And so I have to make my case using my own evidence."
"When you look at the practice of care management, each specialty of case management uses EBP differently; they have their own little niches for what the evidence is in their setting," she added. "The challenge becomes the integration of that over the transition of care for one patient because you can have multiple care managers with different standards based on practice environment."
EBP impacts the outcome of care on all sides and while it can be difficult, a middle ground must be found.
A Middle Ground
Through established standards of care case managers working in all specialties make decisions to optimize patient care as well as cost, but in order to achieve the highest level of care the transition from each discipline to the next needs to be seamless.
"The transitioning of care requires all parties to be communicating and to have the same goals in mind for the patients, which means they have to have free exchange of information and work together to keep the patient out of the hospital," said Tynan-McKiernan.
Healthcare professionals across the country are working to fill-in the gaps.
The Centers for Medicare and Medicaid Services' Community-based Care Transitions Program (CCTP), which was created by Section 3026 of the Affordable Care Act, aims to improve transitions, improve the quality of care and reduce readmissions while maintaining cost effectiveness.
Yale-New Haven Hospital, a participant in CCTP, recognizes the importance of a smooth transition.
"We are early in the process, but it has provided energy and excitement to the staff because they are able to really follow through with patients and families to keep them out of the hospital," highlighted Tynan-McKiernan.
While communication and teamwork among case managers is key, it is equally important to educate staff at all levels, particularly the bedside nurse.
"An understanding of case management even to the non-case manager makes a difference," said Huber.
"Nurses at the bedside are managing that case on a very intimate level long before that patient is assigned to a case manager. We need to educate nurses on where the patient goes from there."
By educating the bedside nurse in case management, the patient will have a better understanding of how their own care will be facilitated going forward, which also helps in the elimination of avoidable rehospitaliztion.
"Success is found through education, not only of other healthcare professionals, but also patients," emphasized Huber.
Better understanding on the part of patients, gives them more control over their own lives, stressed Tynan-McKiernan.
"Accessing care is very difficult and there are so many different care providers," she added. "Everyone is reaching out to patients. They are getting phone calls from insurance companies, hospitals and even pharmacies. The patients need help and need to know who to go to for support."
Just like any other nurse, case managers are patient advocates. And when deciding what course of action to take, they not only have to take into consideration what is best for the patient, but also what their expectations are.
"Advocacy is huge," said Huber. "You have to be able to work with and for the patient, to get them to not only their highest physical functional status, but also taking into account their own perceived functional status."
What quality of life do they want to return to? This question is an important driver of care management.
"The conversation you have with a patient who is an office worker is very different than the one you have with a fireman," explained Huber. "If the guy can't be a fireman, but he can work in a Starbucks that's great he can be a working, functional person, but that is not his perceived optimal functional status."
"That is what case management is," she added. "Taking not only the clinical evidence, but also the patient's background and expectations and putting it together for the best overall outcome."
Patient- centered care planning is necessary. Great case management is not "cookie cutter" case management.
Helping patients transition through each area of care is difficult, especially when the best practices change with each specialty, but through communication, common goals, education, and advocacy it can be done while achieving the highest level of care.
"You have to be well-versed in the evidence surrounding whatever it is you want to accomplish," said Huber. "You have to own it, be able to articulate it to all members of the team, and at the same time you have to be flexible."
"There is always a best practice plan A and there is always plan B," she stressed. "Know what plan B is before you even start plan A because you have to be able to regroup quickly otherwise care can be interrupted while time and money is wasted."
Healthcare providers and patients both rely on the knowledge and support of case managers. "This is an exciting time to be in case management," added Tynan-McKiernan. "With the right resources in the right setting we can really make a difference."
Catlin Nalley is assistant editor at ADVANCE.