Care coordination or discharge planning

by Stefani Daniels, Founder and Managing Partner
Published on Dec 14, 2018

Coordinating care for selected high risk patients across the continuum is particularly important under value-based care contracts. Patient education, sharing information among providers, follow-up with patients and families, and advocating for the Triple Aim will help reduce complications, optimize recovery, and prevent avoidable re-admissions as well as unnecessary admissions.


The fact is, most hospital case managers (HCM) spend their time creating discharge plans and then spend more time executing all the logistics associated with implementing the plan.  And while the patient's hospital case manager is scurrying around or sitting in front of a computer hunting, phoning, faxing, and filing, case managers from the patients' payers and other providers  (eg: worker's comp, ACOs, cancer care, rehab, insurance companies, self-insured corporations, Medical Homes) are working around the HCM and connecting with care team members to make sure that their member or patient has a treatment plan in place that reflects the patient's preferences, is in synch with treatment goals established between the patient and another provider, and is evidence-based to avoid excessive interventions that could place the patient in clinical or financial harm. .  

If you doubt this is what's happening, join me as I travel the country and observe this new phenomenon. I have had conversations on patient care units with HCMs while the payer case manager, in clear view, has a simultaneous conversation with the patient's physician and husband. I have observed case managers sitting in front of computers or on the phones in their nursing station office space while physicians and residents are making rounds with their patients. I have watched as a pharmaceutical care coordinator met with the physician and patient to discuss a new drug that the physician was recommending. And I have participated in early morning hospitalist hand-off rounds where the lead physician informed her team that she met with the physical therapy manager to arrange an early morning treatment schedule on the ortho unit so that elective patients could leave the hospital by 11 am.   

HCMs have been led to believe that their role is to perform the activities of discharge planning for an entire hospitalized population; and in some hospitals,  they are also expected to be the expert resource on contractual obligations and the rules and regulations governing medical necessity and associated utiization review requirements.  This belief has  been sustained by professional organizations that have remained silent while our most vulnerable patients are deprived of a pro-active advocate among their clinical care team. And so, they are exposed to needless medical testing that some pundits place at $200 billion in avoidable healthcare spending. Johns Hopkins researchers Makary and Daniel report that of the estimated 250,000 people who die each year due to medical errors, "Most are the result of systemic problems stemming from challenges such as poorly coordinated care.......as well as variation across physician practice patterns that lack accountability.

Discharge planning has always been the responsibility of the patient's nurse who best knows the patient. Every initial patient assessment which must be completed by the admitting nurse includes a section on probable post acute needs and the initial plan. Every EMR vendor includes this essential document within the nursing application. However, over the years, case management leaders have enabled nurses to disregard that section while their case managers fill the void. Indeed, in many organizations I visit, that section is now titled 'case management discharge assessment.'  "The fault, dear Brutus, is not in our stars, but in ourselves." 

In this new marketplace, hospital case management leaders - as well as our professional organizations - have a unique opportunity to change thinking about the purpose and vision of a value-based case management program.  We have a unique opportunity to go back to the future and transform  the quasi 'discharge planning departments' into care coordination programs.  And nursing has a unique opportunity to return to patient centered care that takes into account what services their patients might need to keep them on the road to recovery or help them remediate their chronic illness. Creating a discharge plan, which requires professional skills, does not mean that the professional nurse has to execute the plan.  In fact, according to the Discharge Planning Association, every hospital should have someone to offer "support to hospital staff in the development and implemenation of discharge plans."  With the proliferation of post acute and extended care options and the requirements associated with the selection and eligibility processes, the task is more appropriately assigned to support staff, available 7 days a week, who become the expert 'consultant' to the HCM (see PARC Ranger). You do not need a professional license to make the post-acute magic happen. 

It is not surprising that every article on healthcare reform identifies care coordination as an essential component of the broad efforts currently underway in the marketplace to improve quality and efficiency in the new value-based system. To be a part of this new environment, HCMs must learn new skills, particularly in the areas of collaboration, communication and advocacy.  Program leaders must establish training programs to enhance care coordination skills and must redesign processes that enable the use of these new skills in hospital practice.  Executives must embrace a value based strategy before its too late and they must work to establish a culture of care coordination so that it becomes a core competency of the organization.  Together, executive sponsors and program leaders must consider how to effectively extend case management practice goals beyond the boundaries of the hospital to provide seamless care coordination to selected patients across the continuum. As never before, professional case managers are needed as essential navigators to those needy patients who deserve the best of what our healthcare system can offer. 

To my dismay, over the years, my enthusism about the essential role of the HCM has dampened as I observe first-hand the decline of their practice. If HCM leaders and our professional organizations won't take a stand against, what in my opinion is a diminished and less distinguished role, then I believe its time to stop using the title case manager and use discharge planner. And while you're at it, join the National Discharge Planning Association.