Ensuring that patients understand their discharge instructions and can afford their medications are two ways embedded case managers can support the hospital discharge, says Irene Zolotorofe, RN, MS, MSN, and administrative director of clinical operations at Bon Secours Health System. Dispensing with these two red flags either on-site or telephonically could ultimately save time and healthcare costs.
The big focus for us with any patient post-discharge or with telephonic calls is whether they understand their discharge instructions. We do the medication reconciliation with them; that’s the most critical element. When they do the review, does the patient understand their medications? Why are they taking their medications? What are they taking? We go line by line with them through their medications and make sure they understand the medications they are taking.
If at any point during that conversation we feel the nurse navigator and the patient need to meet to do medication reconciliation, we’ll either bring the patient into the office or go out and see the patient. Or we will use one of the resources available to us to make sure that the patient is able to correctly take their medication.
The second piece is whether they are able to afford their medication. What kind of labs do they have post-discharge? What are those follow-up appointments? We make sure that we help that patient navigate through the system.
We also try to determine whether they understand the red flags for discharge. When do you need to call the doctor? When do you need to call the nurse navigator? Then, bringing that patient in for that follow-up appointment is critical in making sure we can get them to us. Usually our follow-up appointments occur from between two and five days following their hospitalization. If it is a specialty practice, we follow the guidelines of that specialty practice, but for the most part, with any post-hospitalization, we are trying to get them in within that first seven days of discharge.
Essentials of Embedded Case Management: Hiring, Training, Caseloads and Technology for Practice-Based Care Coordinators documents the experiences of Aetna and Bon Secours in the recruitment, education, workload management and IT support of practice-based case managers.