Improving Transitions of Care in Case Management

By Sophia Kroon
 Stacey Hodgman is the District Director of Case Management, Kindred Hospitals Massachusetts District.
Stacey Hodgman is the District Director of Case Management, Kindred Hospitals Massachusetts District.

Kindred Healthcare’s Massachusetts District has recently been charged with conducting a pilot project to improve transitions of care throughout the continuum. “The project is called Better Together,” says Stacey Hodgman, MS, RN-BC, CPUM, CCDS, District Director of Case Management, Kindred Hospitals Massachusetts District. “Our goals are to improve care coordination and patient outcomes and to become the post-acute leader and partner of choice in the market.”

 The Kindred Massachusetts District has four lines of business: 1) long-term acute care hospitals; 2) skilled nursing facilities; 3) PeopleFirst home care; and 4) PeopleFirst hospice care. “We’re looking to align our clinical programs across the continuum utilizing best practices through evidence-based clinical pathways so we can safely transition patients to the next level of care and ensure the best possible outcomes,” Hodgman says.

Although the project is still in the early planning stages, several possible methods for improving transitions of care have already been identified. Each of these strategies is dependent upon the patient’s active engagement in his or her treatment plan, decision making, goals and discharge plan:

  • Providing both a verbal and a written handoff from case manager to case manager for every patient transition encounter
  • Including a nurse or case manager from the facility the patient is transitioning to in the patient’s discharge planning meetings
  • Ensuring patient understanding (through best practices) of his or her disease processes and management, medications and treatments, equipment and restrictions, follow-up care, and when to call the doctor and/or seek emergency care
  • Improving the timeliness of discussions with patients and their caregivers about hospice and palliative care options when appropriate
  • Conducting post-discharge follow-up calls at pre-determined intervals to the patient or caregiver and to the patient’s care provider (nursing facility or physician)
  • Notifying the patient’s PCP of the patient’s summary of care and discharge disposition with each transition of care

Once the project has been designed, evaluated and determined to be successful, Kindred plans to implement a collaborative post-acute continuum on a national level. “Health care is so fragmented right now,” says Hodgman. “We see the sickest of the sick. It’s vital that we improve communication during transitions of care so that patients can achieve optimal health and health care providers can improve resource utilization.”

Stacey Hodgman is the District Director of Case Management, Kindred Hospitals Massachusetts District.