Case Management

Add this best practice to improve your results with patients

Case Management Insider, November 17, 2015

If you spend more time looking at charts than patients, you might be missing important opportunities to improve care and prevent readmissions.

Face time with patients is critical, says Karen Zander, RN, MS, CMAC, FAAN, principal and co-owner of The Center for Case Management in Wellesley, Mass. To truly get a grip on a patient’s condition and needs, the case manager needs to sit with the patient, not just look at a computer screen, says Zander. “Charts are imperfect. The medical record, no matter how good, is not a perfect document. It could never tell you, for example, that the patient smells strange or has bad breath,” she says.

Knowing those things can help you better determine how the patient will fare after discharge and what support services he or she might need.

To better help you identify potential risks the patient may face after discharge, it’s also a good idea to use a readmission risk assessment when the patient is admitted. This can help you identify potential problems early in the hospital stay so you have sufficient time to prepare for and manage them.

There are a number of risk identification systems out there, and Zander says there really isn’t an official consensus on which is best. “We’re still in a national learning curve about what constitutes a risk for readmission,” she says.

Many organizations have successfully used a tool created by Project Boost to identify risk. This system assigns patients a risk score based on eight Ps, says Zander, which include:

  1. Principal diagnosis—risk is higher, for example, if the patient has a diagnoses such as cancer, pneumonia, heart attack, chronic heart failure, chronic obstructive pulmonary disease, or diabetes
  2. Prior recent hospitalization
  3. Poor health literacy
  4. Psychological issues
  5. Lack of patient support
  6. Polypharmacy, risk is higher if the patient takes more than eight medications
  7. Problematic meds—risk is higher if they take a medication with a high-complication rate, such as insulin or Coumadin
  8. Need for palliative care—risk is higher if they need palliative care and aren’t getting it

A high-risk patient scores four or more Ps.

Meeting with patients directly and using assessment tools can help you get ahead of potential issues and prevent the patient from winding up back in the hospital after readmission.

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