February 27, 2018 | Susan Pasley, MS, BSN, RN

Discharge series: coordinating care

Care coordination and care transition are buzz words in healthcare today. While they receive a lot of attention, coordinating a patient’s healthcare journey along the continuum can often times be difficult outside the ED where other circumstances are a factor. This can be true regardless of whether a patient is suffering a relatively minor condition or managing a complex diagnosis with comorbidities. Collaboration is key when coordinating a patient’s post-ED care, whether you’re using internal resources or outside providers.

Collaboration with referral providers

The ED provides referrals with the intent of getting patients to the right level of care for ongoing treatment. Although making a referral is relatively simple, the information exchange between providers is often lacking. It is essential that the ED provides the referral physician with details about the patients’ presentation, acuity, diagnosis, tests and treatments, treatment plan, and expected plan of care. Technology has improved this process through the automated distribution of discharge summaries, but organizations must ensure that information sent is timely, accurate, and complete to reduce unnecessary testing and provide seamless care transitions. Even with strides in technology, there are inconsistencies in this vital communication. Collaboration with community providers can create shared accountability for managing patients across the care continuum.

ED-based case management

For patients who have suffered a health crisis, making the transition to the home environment can be challenging, and social determinants of health often further complicate this process. Care coordinators or case managers in the ED provide a valuable resource to assist with transitioning high-risk patients. They can assist in addressing barriers to recovery such as finding housing, health insurance, transportation and a primary care provider for patients in need. The dyad model of a care manager and nurse has also been effective in the ED.

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  1. Bristow DP, Herrick CA. Emergency department case management: the dyad team of nurse case manager and social worker improve discharge planning and patient and staff satisfaction while decreasing inappropriate admissions and costs: a literature review. Lippincotts Case Manag 2002;7(6):243-51.