Partners Across the Continuum
Case managers are responsible for insuring the safe transfer of patients or clients to the most appropriate healthcare provider or care setting. The coordination of the transfers occurs in a timely and complete manner (Newman, Fraser, 2016). The hospital case manager must transfer or refer patients, along with necessary information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up ancillary care (CMS.gov, 2016).
Continuity of care incorporates care of an individual patient over time by bridging discrete elements in the care pathway. Although geriatric patients are transferred between different levels of care to accommodate their increasing medical needs, many of these transfers are associated with errors in communication; preventable adverse events; and patient, caregiver and provider dissatisfaction (Cortes, Wexler, Fitzpatrick, 2004; Crilly, Chaboyer, Wallis, 2005).
The case manager community has learned over the years the essential detail that must accompany each transition, particularly those of our vulnerable elderly. Relocation occurs frequently among older adults due to situations threating their independence, such as acute or chronic illness, a decrease in functional abilities, a decrease in cognitive abilities, socioeconomic changes and changes in the family structure (Laughlin, Parsons, Kosloski, Bergman-Evans, 2007).
The hospital case manager creates relationships with partners across the continuum that participate in continuity of care for our elderly and vulnerable patients who cannot safely return home alone. The post- acute care possibilities for patients and clients today are broad in scope and include skilled home health care, non-skilled home care, skilled nursing facilities, day care facilities, assisted living facilities and long-term care facilities.
The case manager is the expert professional who guides patients, clients, veterans and their caretakers to make the right decision about the safest, most economical and least restrictive post-acute environment. There are many selections today for our clients, patients and veterans after they leave the hospital. In this issue, the myriad of options for post-acute care are highlighted by the experts who deliver the programs, services and habitat.
Whether we as case managers are working with our patients, veterans, and clients to explore post-acute care possibilities, or working with family members to do so, this issue will provide you excellent information to inform your important work.
Thank you for your commitment to case management.
Mary McLaughlin-Davis, DNP, ACNS-BC, NEA-BC, CCM
President, CMSA 2016-2018
Dr. McLaughlin-Davis is the president of CMSA. She has been a certified case manager since 1993; she is a clinical nurse specialist for adult health and the senior director for care management for Cleveland Clinic, Avon Hospital.
Case Management Society of America. (2010) Standards of Practice for Case Management. Little Rock, Arkansas: Marion, C.; Lattimer, C.; Marshall, D.; Powell, S.; Chu, M.; CMS Conditions of Participation. (2016). https://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/Hospitals.html . Retrieved June 13, 2016.
Crilly, J., Chaboyer, W., Wallis, M., (December 2005). Continuity of care for acutely unwell older adults from nursing homes. Nordic College of Caring Science 20, 122-134.
Laughlin, A; Parsons, M; Kosloski, K; Bergman-Evans, B. (2007). Predictors of Mortality following Involuntary Inter-institutional Relocation. Journal of Gerontological Nursing, Sept. 20-26.