Case management involves a wide range of services, including care management while a patient is hospitalized, discharge planning, and follow-up care. In the case manager’s eyes, discharge planning is perhaps one of the most challenging aspects of the job. Discharge from the hospital is a critical point in a patient’s recovery, especially for older people who suffer from chronic conditions like heart disease and diabetes. Making sure a patient and their primary caregivers are ready for the return home and subsequent care is a vital element that can significantly influence patient outcomes.
In fact, according to a 2009 study (1) published in the New England Journal of Medicine, about one in five Medicare patients are readmitted to the hospital within 30 days of their discharge. Readmissions are a tremendous stress to the patient and the hospital. And in most cases, readmissions are a result of a medical event that could have been prevented.
At Good Samaritan Medical Center, we have developed innovative health promotion and disease management programs that are incorporated into our case management and discharge planning. These programs aim to reduce readmission rates by offering community outreach and prevention as part of our care transition from the time patients are admitted into the hospital to their healthy return home.
Since diabetes and heart disease are prevalent in our community and patient population, we’ve focused on developing two programs- “Heart Strings” and Diabetes Education- to promote health and reduce readmission rates related to these two chronic diseases. These two diseases can be well controlled in the hospital, but it’s a different story when the patient returns home and faces major lifestyle and health changes.
The “Heart Strings” outpatient program provides education and support to help patients and their families understand and manage heart failure post-hospitalization. Every Tuesday, the support group meets to discuss important topics such as Heart Failure Management; Heat Failure Medications; Dietary Guidelines for Heart Failure; Exercise; and the Psychological Impact of Heart Failure. We’ve learned that patients need support not only from case managers and the medical team, but also from their peers who are equally experiencing the same challenges related their heart failure diagnosis. This emotional support is a key factor in motivating patients to make the lifestyle and health changes necessary to manage their disease.
Like heart failure, patients with diabetes often have difficulty managing and coping with their disease on their own. With this in mind, we developed the Diabetes Education Program that meets the National Standards for Diabetes Self-Management Education endorsed by the American Diabetes Association. Certified Diabetes Educators, Registered Nurses, and Registered Dietitians, and Case Managers provide small group classes and facilitate support groups to help not only people living with diabetes, but also people who are at risk for the disease. Our physicians are directly involved, as they must write a prescription or order for a patient to participate in the group. The group meets every Wednesday and Thursday at the hospital and helps give patients the self-management tools they need to manage diabetes and maintain healthy lifestyles.
In sum, case management requires a lot of critical thinking, compassion, and knowledge of the complex healthcare web. Discharge planning is one very important aspect of this web, and it can significantly impact patients’ health outcomes. A critical component of our discharge planning now involves community outreach, education and prevention, which offers patients something that no medicine or medical treatment can provide: empowerment. Patients must be an active participant in managing their healthcare, and these are the tools our programs aim to provide. In turn, our patients are healthier and happier to be part of Good Samaritan Medical Center in a positive way.
