Brocato says the three hospitalists at Cabrini have been easy to work with, sometimes seeking out the case managers and social workers to ask for their help on difficult cases, working with their fellow interdisciplinary-team members to design discharge plans from innovative ideas that solve patient’s challenges, and including the patient in their planning.
Appropriate Levels of Care
At Cabrini Hospital, the case managers and social workers hold daily interdisciplinary discharge planning meetings. Each case is reviewed according to nationally accepted criteria to ensure that the care provided meets standards appropriate for the acute inpatient level of care. Other treatment levels identified during discharge planning include rehabilitation, long-term acute care, and outpatient levels of care.
One recommendation that Brocato would make to hospitalists to better help the work of the case managers, the hospital, and the patients is to recognize earlier which patients will require a longer length of stay (more than three weeks) so that those individuals can be transitioned into a more appropriate level of care.
Some examples of diagnoses in which long-term acute care might be called for, she says, include “osteomyelitis, where a patient will be on a course of antibiotics for six weeks and may require extensive wound therapy. In that case, as soon as we get the results of the bone scan and we see that, we immediately ask the physician to think about moving the patient.”
Other examples include those patients who will need a long time to recover, such as those in the ICU. “Maybe they’ve have been on a ventilator for a long time and they get debilitated,” says Brocato. “Or if they need to be weaned from the ventilator and need some intensive respiratory toilet. The long-term acute care setting is the more appropriate setting to work on trying to rehabilitate the patient.”
Follow-up
Another important element to a good discharge plan is follow-up. Cabrini Hospital has initiated a program whereby a nurse has been hired to call on patients within two days of discharge to check on how things are going. That is, Brocato says, “whether they understood the discharge instructions, to make sure that they got their prescriptions, and [to ensure] they have some kind of follow-up appointment made and are planning to go to that.”
A 2001 study conducted by the section of general internal medicine in the department of medicine at West Virginia University (Morgantown) showed that the effect of employing a nurse discharge planner to work with the hospitalist service had a positive effect on outcomes in an academic teaching hospital.1 When a general medicine service, specialist-staffed service, and a hospitalist service with nurse discharge planner were compared, the hospitalist-discharge planner group was associated with a lower average cost and shorter average length of hospital stay. There was no apparent compromise in clinical outcomes and patient satisfaction with care.
Competent Colleagues
The American Case Management Association (ACMA), begun in 1999, is the first and only nonprofit hospital-based case management organization in the United States. It represents nurses, social workers, physicians, and other professionals who practice hospital case management. The physicians whom ACMA represents are primarily medical directors hired as the catalyst for attendings who are less than cooperative and are impeding discharge (typically not the hospitalists). “The organization is growing at an average annual growth rate of 25%,” says Cunningham. “We’ve just started a new certification process for hospital-based case managers—one for nurses and one for social workers.”
There is a core portion to the exam that tests for knowledge, and a specialty portion of the exam in which “they have to validate those skill sets. The specialty portion of includes a clinical simulation, which is the application of their skills and knowledge,” explains Cunningham. “They have to [show that they can] make not only a decision, but sequential decisions. So we’re testing their ability to take a case and work through it.”