Improving Care Management Services

A major part of care management services is reducing hospital readmissions. Reduced hospital readmissions lead to better quality care, lower length of stays and complement extended care post-hospital stay. As hospitals seek to improve their Care Management Services let’s discuss ways they can do this by reducing hospital readmission.

Start Discharge at the Time of Admission:

When a care manager learns that a patient is readmitted, they contact the case manager at the hospital or skilled nursing facility. This initial contact lays the groundwork for a successful discharge that lowers risk of readmission. Communication about discharge between the transitional care manager and hospital or facility case manager is particularly critical. As hospital stays become shorter in duration, care is best coordinated when the community or transitional care manager collaborates on discharge plans with the facility care manager immediately upon admission. A follow-up call to the patient within two days of discharge is important to assess the patient’s condition and understanding of prescriptions,  and to educate them on signs and symptoms that should prompt a call to their PCP.

Ensure Medication Education, Access, Reconciliation, and Adherence:

When a person is hospitalized, either due to a chronic or a new acute condition, it is likely that the patient will receive a new prescription or a change in medication. The transitional care manager must cover the following key points regarding medication: Education: The care manager works with the care team to teach the patient or caregiver about all medications—what they’re for and how (i.e., with or without food) and when to take them. This includes an understanding of the risks of missed doses and what to do if they miss a dose. Education should be completed prior to discharge. Access: Access to medication includes both the ability to get to the pharmacy to pick up prescriptions and the ability to pay for them. Prompt pick-up is particularly important with certain medications; with antibiotics, for example, a delay or interruption may cause an infection to return.

Before patients are discharged, the care manager verifies with the patient or caregiver that they can access and afford their medications, or connects them with resources to help (such as elder services or a social worker from the PCP practice or from the discharging facility). Reconciliation: The care manager can collaborate with the facility or practice pharmacist, if there is one available, on medication reconciliation. The pharmacist can play a vital role in obtaining an accurate medication list (inclusive of new prescriptions, over-the-counter medications, and pre-existing medications) for the patient’s follow-up visit with the PCP. Ideally, this reconciliation should be done at the time of, or immediately after, discharge.

Adherence: Care managers can help patients and caregivers understand the importance of adhering to the medication plan. How likely is the patient to take the medication as prescribed? Is there a literacy or understanding issue that might prevent them from taking the full course of medication or taking it every day at the same time?

Arrange Follow-Up Appointments:

Care shouldn’t stop when the patient is discharged from the hospital. Upon discharge, the Care Manager makes sure the patient has a follow-up appointment with their doctor seven to 10 days after discharge. Patients should not skip the doctor follow-up, even if they have plans to see a specialist. The doctor is the continuum-of-care point person, meaning they need stay informed of all other care to avoid prescription contraindications, conflicting clinical plans, confusing or contradicting patient instructions, and other adverse events. Likewise, the care team pharmacist or care manager must conduct a medication reconciliation to obtain a current list of prescriptions, including any new medications given in the hospital or upon discharge. This medication list should be given to the PCP before the follow-up appointment.

Have Patients Teach Back the Transitional Care Plan:

The final, indispensable step in the transitional care management framework is having the patient and caregiver teach back the care plan. This is how the care manager confirms that they’ve successfully educated the patient on their discharge plans, diagnosis, medication, and when to call their PCP. It confirms the patient’s understanding of the follow-up appointment with the PCP. The care manager gives the patient a number to call with any questions.

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