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Case management teams are being celebrated nationally during Case Management Week, Oct. 12 through 18. USA Medical Center held a breakfast in appreciation of its Case Management team and all it does for patients.
The nurses and social workers who handle case management don’t often get thank you cards and cookies from patients and families they’ve helped — mostly because the patients and families barely know them. Compared to doctors and nurses who work at the bedside, these teams are nearly invisible.
But the team that handles case management at USA Medical Center finds the work rewarding, nonetheless, because they know they’ve been able to help.
“It’s rewarding to know that you’ve helped somebody in their recuperation period — to know that they’re able to move on,” says social worker Beth Poates.
Co-worker Debbie Brannon, a nurse who does discharge planning, says, “I love what I do. It’s very challenging and I love it when a plan comes together. I love it when it works.”
“Our main priority is to get patients the care they need,” says utilization review specialist Patricia Johnson. “All parts of the team work together to see what patients need. It’s the best collaboration I’ve ever been involved in.”
The value of the role this team plays is being celebrated nationally during Case Management Week, Oct. 12 through 18.
The concept has been around since the 1970s, says Tina Barbour-Taylor, R.N., director of the care management department at the Medical Center. The whole concept has become even more important in recent decades because payers and federal regulations are demanding shorter stays and better outcomes.
“We help facilitate discharge as quickly and safely as possible,” says Barbour-Taylor.
“This is a good system,” says Barbour-Taylor. All the new regulations mean that hospitals would go broke if they kept patients hospitalized till everything was perfect. “With case management, we ensure that patients get the quality of care they need, so they can get discharged when they’re stable and have the follow up care they need.”
Johnson’s role begins as soon as a patient is admitted, with a pre-assessment before surgery. She helps patients and families think through whether they have the resources they need, the equipment, the access to rehab and a clear understanding of what to expect following major surgery.
She helps them work through the paperwork. What will their insurance or Medicare or Medicaid pay for and what will it not pay for?
She also works to ensure that the hospital gets the reimbursement due to it. That’s not a self-serving concern, she notes. “If we have no reimbursement, we’re not viable to help the community, and we are very much a community hospital.”
Other team members are more closely involved with discharge planning.
Social worker Poates and discharge planning nurse Brannon coordinate efforts to get equipment, arrange for rehab, find transportation home, make contact with social service agencies like 15 Place if patients have no home to return to.
The team works with agencies such as Goodwill Easter Seals to get wheelchairs and walkers and the like. They work with pharmaceutical companies to get low cost medication, especially very expensive medications.
“We can help people get hospice if needed,” she says. “And we can help provide transportation home.”
“I do this from a nurse’s point of view,” says Brannon. “How can I keep you healthy? What can I give you to meet your health needs once you’re discharged? And I can see what’s not going to work.” A plan requiring antibiotics ten times a day, for example, needs to be modified or else families will need specialized help or transitional care to manage it.
“A lot of different people have a lot of different needs,” says Poates. “We may not be able to provide it, but we can put them in touch with the people who do.”
“Sometimes patients have no family,” she adds. “Then you have to work things out for them.”
And sometimes they need to find resources out of the area or even out of state. “If somebody’s on vacation here and gets in a car wreck, they need follow up back where they’re going.”
For them, “we’re the support group,” says Poates. “We’re there when nobody else is.”
“Working together for the patient is the best part of it,” says Brannon.
“Traditional nursing is being by the bedside,” says Johnson, “but this is an important role, too — handling the transition of care, making sure somebody is looking after the other side of things.”
About the University of South Alabama Medical Center
The University of South Alabama Medical Center offers patient-centered care to the central Gulf Coast with unique services including Mobile’s only Level I Trauma Center and Regional Burn Center, plus Centers of Excellence in stroke care and cardiovascular diseases, and a wide range of acute care services.
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