This summer, the U-M Health System began improving how care is delivered to our patients through an initiative called Care Management.
Previously, discharge planners and social workers were assigned to specific services throughout the U-M Hospitals and Health Centers. Now Care Management designates a social worker and discharge planner to assist each unit based on where patients are located. Through the model, RN case managers are physically present on their assigned unit, connecting with patients, teams and providing support.
The initiative began in August with rollout on inpatient units in 5A, 5B 7C/D, CVC4 followed by implementation on all C.S. Mott Children’s Hospital inpatient units on Sept. 16. Following implementation, teams have been rounding and working with individual units to determine what is working well, and identify issues for resolution.
Christopher Title, RN, BSN, clinical nurse supervisor at the Cardiovascular Center on ICU CVC 4, has already begun to see improvements on his unit.
“This initiative has changed our workflow in a lot of positive ways,” says Title. “It has increased communication and made the process for transferring patients out of our unit more efficient.”
“The Care Management model has allowed us to better identify the patient’s transitional care needs and move them through the system quicker.”
As part of Care Management, Title’s team comes together each weekday to discuss the patient plan for the day, the plan for the patient stay, potential barriers to implementing the plan, along with clarifying assignments of members. The daily team “huddle” consists of the advance practice team, charge nurse, case manager, social worker, nursing management representative, and bed coordinator.
Title says, “this type of daily collaboration and communication has led to improved transitional care within our facility, the right care in the right location for our patients, along with reducing the transfer times to outside extended care facilities” – important objectives of Care Management.
“When caring for patients, focusing on the family is always a priority,” adds Title. “Our CVC-ICU social worker Liz Rodems now works with case manager Cathy Kolpacki to identify issues like how patients will get home and who will to take care of them during those care transitions. In addition, our charge nurse works closely with all team members to assure transitional care needs are met.”
In addition to improving patient care, the program is improving staff workflows and satisfaction.
“It has been great to have Liz and Cathy right on our unit,” says Title. “We used to have to page or call a social worker and wait for help. Now they are there every weekday to help. Our staff loves that.”
What is Care Management?
The goal of unit based Care Management is to improve communication and coordination of care through integration of discharge planning, utilization review, social work and more even distribution of case manager workload. In addition unit-based case managers and social workers are expected to interface with nursing and other care team members on the unit each day to ensure the plan of care is communicated and carried out in a timely and efficient manner as well as to ensure smooth transitions of care at discharge. They will coordinate with outpatient providers, home care and other services.
Additional information about Care Management, including resources and communication updates, can be found at http://www.med.umich.edu/i/caremanagement/