Case Managers Key to Successful Care Transitions

Tuesday, July 12th, 2011
This post was written by Jessica Fornarotto

When it comes to care transitions, Geisinger Health Plan case managers place their focus on medication reconciliation, explains Doreen Salek, BS, RN, CCS/CPC, director of business operations of health services for Geisinger Health Plan, and Janet Tomcavage, RN, MSN, vice president of health services for Geisinger Health Plan.

Case managers focus on the highest risk patients in that practice. They may or may not have common chronic conditions such as diabetes or heart failure (HF) but they may just be frail elderly who will have dementia or who were just getting frailer and cannot live alone safely in their current condition. We focus on the highest risk patients at that site and what’s driving the conditions or the experience for the patient. For example, if it is HF, we work with the patients and the provider to design a plan of care that’s going to get at that HF. What do they need to do when their weight starts to go up? Do we need home care involved? If they’re hospitalized, what do they need to know now to prevent a hospital readmission? We focus on the driver of their conditions.

Transitions of care are another core component of the case managers. They get notified about every admission and discharge from their site, and outreach telephonically to every discharged patient within 24 to 48 hours. They focus on a series of issues: medication reconciliation and making sure that what was changed, adjusted or added in the hospital is accounted for on the outpatient side. Has the patient filled their prescriptions? Do they have the money to get them? Do they have access to the pharmacy to get them filled? We found early on that patients who get new prescriptions take them home but do not fill them until they got their PCP’s blessing. We also found many medication errors, such as the patient at home who was on Metoprolol but who was put on Topherol in the hospital — two beta blockers or two ACE inhibitors. Case managers make sure that there is a clear understanding of what the patient is taking or should be taking at home. Medication reconciliation has been a huge focus and a huge win for us.

We also focus on:

  • Is the patient safe in their home?
  • Are they well enough to be caring for themselves?
  • If not, do they have good, strong social supports to help take care of them in the house?
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