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Mentor moment: Think of case management as a proactive team

Case Management Weekly, February 16, 2011

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The nuts and bolts of case management operations involve a collection of disciplines with whom case managers work closely while managing their individual assignments. Nurses, physical therapists, dieticians, pharmacists, respiratory therapists, wound care specialists, and dialysis nurses aid in the planning of a patient’s smooth and effective transition to the next level of care.

Early rounding with treatment team members helps identify roadblocks that prevent the transition of patients to other levels of care or to home. Their input may provide information that may not be documented yet. This is helpful because delayed documentation can delay discharges if a case manager receives important information late in the process. This collaborative approach also promotes team bounding and fosters an appreciation of the efforts everyone puts forth in the treatment of patients.

Once case managers identify the discharge destination, they must communicate with the primary care nurse. Early support from the primary care nurse can mean a two to three-hour discharge rather than a five to six-hour discharge. These hours are valuable to case managers who work on multiple discharges simultaneously. When communicating with the primary care nurse, describe the information and actions required to create an effective and timely discharge plan for the patient.

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