One of the riskiest times for patients comes when they are leaving the hospital and heading home or to aftercare. This is the time when medications are mixed up, follow-up doctors' appointments are missed, or discharge instructions get lost in the fax machine. Poor handoffs with poor communication can lead to unnecessary readmissions.
Utilization review (UR) and case management are as traditional a team as peanut butter and jelly. But some facilities are asking whether this longtime duo is really the best combination.
In December 2011, Detroit Medical Center (DMC) got word that it had been selected as one of only 32 medical organizations in the country to participate in Medicare's new Pioneer Accountable Care Organization (ACO).
So you've looked at your readmission data, and you've found a problem. One nursing home or SNF is sending back a large number of patients for readmission within 30 days.
Many case managers today feel like they're overburdened, but it may not be clear whether they're actually shouldering too much work. This is because the industry doesn't really have any validated figures indicating what the typical caseload is-or should be, says Pat Stricker, MEd, RN, senior consultant at CMI in Little Rock, AR.
New nurses just out of school often find themselves at work alongside veterans who have little patience for those who don't perform at par. It's no different for nurse case managers.
Case managers want their patients to leave the hospital with a successful transition to home or aftercare and not have to return to the hospital unnecessarily.
