Q&A: Warm handovers to improve workflows and care transitions

Q: Do you have any advice for helping a case management team improve workflows between the inpatient and ambulatory setting?

A: Warm handovers are intentional conversations (in person, if possible) between case managers and social workers across settings. When a patient is identified in the inpatient setting as having a potential risk for readmission or significant clinical or psychosocial challenges, schedule a meeting with the inpatient and the ambulatory case manager and/or social worker in the patient’s room with their family on-site (when applicable). Have this handoff the day before discharge, as the day of discharge can be quite chaotic. Additionally, if a patient is being admitted (e.g., surgical procedure, planned admission) with significant issues, connectivity between the case managers/social workers between the sites is equally effective.

The key is for the patient/family to recognize who will support them through their recovery and/or chronic illness issues.

Now that there is a propensity for patients to move through several postacute levels of care, the case manager should ensure continuity of care by sharing the information they have with all future providers in case management.

Additionally, as preferred provider networks become essential to the financial health and stability of the system, case managers must ensure that the patients remain within the system, no matter how far in the future the care is being determined. For example, if a system owns a home health organization but the patient is going to a skilled nursing facility (SNF) first, the case manager in the SNF as well as the intake coordinator of the home health agency must have this patient on their radar.

For more information see: Care Transitions in Case Management.