Patient Advocates Help Navigate Health Systems To Ensure Seamless Transitions

 
Riverside Walter Reed Hospital enhances Care Management program and celebrates National Care Management Week
 
Verifying insurance will pay for a hospital stay. Making it to doctor's appointments.  Meeting with specialists. Having prescriptions filled. All these steps, and more, can be part of a patient's journey through dealing with a health issue. Riverside Walter Reed Hospital recognizes that navigating a health system and juggling moves from a hospital setting to home and then back to a doctor's office when you're sick or injured, all while dealing with the emotional toll of a health concern, can be difficult.
 
"This is why Care Managers are so valuable," said Steve Beebe, Riverside Walter Reed Hospital's Manager of Care Management. "Riverside Walter Reed Hospital is expanding and enhancing its care management processes – to ensure we can make patients' transitions throughout the continuum of care as seamless as possible."
 
Riverside Walter Reed Hospital's enhancements in the Care Management program comes just as healthcare organizations across the country celebrate National Care Management Week, October 13-19. Taking a week to celebrate care managers – a tradition started in 1998 by the Case Management Society of America – is about more than bringing attention to the contribution case managers make – although that is a goal. It's also meant to raise awareness about the industry and the key role case managers play in a patient's healthcare experience.
 
Officially, care management, also known as case management, is the process of ensuring that the many members of a healthcare team treating a patient work together to assess, treat, evaluate and advocate for services to help a patient and their family move smoothly through the multiple areas and layers of healthcare. In a hospital setting, that means ensuring patients, families, nurses, doctors, social workers, specialty clinicians, caregivers and the community are working together. It can include managing a patient transitioning from a hospital to long-term care, home, primary care physician or community resource.
 
"Care managers are advocates who help patients understand their current health status, what they can do about it and why those treatments are important," according to the Case Management Society of America. "In this way, care managers are catalysts by guiding patients and providing cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently."
 
Care management is not unique to Riverside Walter Reed Hospital.
 
The practice dates back as early as the 1820s when volunteers visited families to assess their needs and educate them on the community resources available. The care management model practiced at large today started to take shape in the 1960s as this type of planning and coordination became more focused on specific healthcare needs.
 
What is unique to Riverside Walter Reed Hospital, though, is its recent enhancements in how it approaches care management.  Today, it includes working more closely with patients from the time they arrive at the hospital, through their discharge and well into their transition back home and into their routine wellness programs, Beebe said.
 
The care management process starts when a patient arrives by taking the lead on what can be the first, most daunting task for a patient and family – ensuring hospital visits are approved by a patient's insurance based on their diagnosis, treatment plan and anticipated length of stay. The care coordination continues with discharge planning, where a Riverside team member works directly with the patient, all hospital staff caring for that patient, the family and convalescent and rehabilitative facilities that will serve the patient once they leave. "What's important here is that managing care doesn't end once you leave the hospital," Beebe said. "We want to make sure our patients get what they need along every step of their healing process."
 
And beyond. Riverside Walter Reed Hospital's newest addition to its care management process includes ensuring patients – both inpatient and outpatient – not only experience those seamless transitions between the various steps of dealing with a specific health event, but also throughout their life. That means collaborating for patients in both an in and outpatient setting and includes social work coordination – helping ensure patients are heading into a safe environment throughout each transition – and ensuring that resources (insurance) are applied appropriately.
 
"We want the community to be able to utilize the services across the healthcare landscape – from home to hospital to rehabilitation and back home – with minimal disruption of their existing wellness regimens," Beebe said. "That means ensuring open and transparent communication takes place between all practices that touch a patient's life in healthcare, from the primary physician's office to home health, the hospital, specialists, rehabilitation, assisted living, adult homes, convalescence, and hospice."
 
Riverside Walter Reed Patient Care Supervisors meet with patients on a daily basis at the hospital to "review their care with them, answer their questions and uncover possible needs the patient may have," Beebe said.
As this new program continues to roll out and grow, Riverside Walter Reed Hospital is looking to offer educational classes to patients, families and care givers on the most frequent diagnoses the hospital cares for – diabetes, COPD, stroke and pneumonia. "We talk about advocating and collaborating," Beebe said. "But it's also about educating."

Published: October 14, 2013



 

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