It should be an exciting time for case managers. Healthcare reform is in it’s creation and The RAC (is it not the perfect nom de guerre?) is knocking on our doors. Yet I hear nothing from our ranks or leadership weighing in on the issues.President Obama recently made notice of an article in the New Yorker by Dr. Atul Gawande. This article was about a Texas city that had the highest cost per Medicare patient in the US. It’s conclusions said nothing that any nurse case manager could not have told him about over utilization. The reform issue of “how are we going to make universal healthcare affordable?” is all about case management principles. If the future of healthcare delivery is going to be based on the principles of the right care and the right time, it is going to take case managers to make it work. Focusing on the here and now, The RAC is the best thing ever to happen to hospital based case management. Hospitals will not be able to survive without strong UR/ case management programs.
Ray Gridey, RN BS, CPUR – Case Manager

In many instances, discharge planning from an acute setting to home requires a collaborative effort among treating physicians, the hospital discharge planner, post discharge home care providers, the patient, and their caregiver. Individuals with complex medical conditions or ongoing needs are often referred to a case manager at their health plan as well.  Health plan case managers are held to the same standards for assessing, planning, facilitation and advocacy for their patients as are case managers in any other setting.  I would like to make a case for including the individual’s health plan case manager in the discharge planning process.   While the hospital DC planner assesses the individual’s needs post discharge and makes referrals and arrangements for post discharge care in the home setting and the home DME and home care agencies provide the actual care and services, the health plan case manager may be very familiar with the individual prior to their hospitalization.  This often puts the health plan case manager in a position to provide valuable insight into the individual’s needs, caregiver issues and other concerns.  Additionally, the health plan case manager is in a unique position to continue coordinating services across the continuum of care.  

As a director of case management at a health plan, my case managers are accountable to coordinate a discharge plan when one of their patients has been admitted.  However, the case managers are reporting an unsettling trend of not being included and therefore not involved in their patient’s discharge plan.  Increasingly, our patients are being discharged and the health plan case manager is not contacted, even after leaving messages at the hospital office of discharge planning.   I challenge case managers and discharge planners in hospital settings to be true advocates for their patients and involve health plan case managers in the discharge planning process, not just for “authorization” of payment but in true collaboration for ongoing care coordination post discharge.

Kimberly Babaie, RN, BSN, Certified Case Manager

Director of Care Management