When I think about the nature of discharge planning and the complexity that is involved, it is no wonder that at the end of the day it is so easy to overlook the most crucial of details. What the most recent shift in healthcare is teaching us is that the most easily overlooked detail is the patient themselves. The idea of changing discharge planning to “transitioning” has merit to it. It seems to force us to focus on the patient’s needs rather than the “to-do” list in order to safely discharge the patient. The process of how each of us transitions our patients is unique based on resources and job descriptions; however the mission at the core is the same. We all want to provide safe and effective transitions of care throughout the care continuum. 

A Turn to Patient-Centered Care

At Group Health Cooperative of South Central Wisconsin (GHC-SCW), a managed care organization, we have shifted our focus to patient-centered care and have reorganized ourselves to support this mission. Where doctors and nurses used to work in silos with the patient, they now form care teams, allowing them to more intimately know their patients. This has also provided patients the reassurance that they will have more than one person who understands their healthcare needs if their primary physician is unavailable. If they need to make any appointment with their primary care physician and are unable, the care team coordinator will try to provide them an appointment with another provider on their care team. When a patient is admitted to the hospital, the primary physician is notified of the admission and diagnosis. In turn, they are also notified of the discharge and discharge orders and are then able to have the care team nurse coordinator follow up with the patient to assist with follow-up appointments and needs.

In addition to the care team design, the care management department has realigned themselves to be an active and present part of the care team. A case manager is assigned to each clinic to be the primary contact for patients requiring complex coordination of care and is present in the clinic at least three days a week. The case managers are able to meet with patients and assist the care teams with complex care needs. The department is diverse, employing both social work and nurse case managers to provide case management services. The disciplines complement each other well, and they are able to collaborate with each other to meet the complex healthcare and psychosocial needs of the patient.

The case manager is aware of every admission for patients at their designated clinic and can talk with the primary care physician about the patient’s care needs. If the patient has complex needs, the case manager will contact the patient and discuss the complex case management program. In collaboration with the patient and care team, the case manager develops a care plan that directly reflects the goals of the patient and the measurable interventions to achieve those goals. The program has been developed to assist the patient for up to 90 days, with an extension when appropriate in order to continue working on unmet goals.