How Case Managers and Care Coordinators Are Working Together and Finding Success in Hospital Discharge Planning

For a hospital discharge coordinator, the success of an injured employee’s discharge planning largely relies upon coordination with a case manager who helps evaluate the injured employee’s discharge needs and collaborates on how best to transition them home or to a facility. When a case manager is engaged, they can deliver multiple benefits and build trust with the injured employee to ultimately support a timely recovery. In the second installment of our series, we’ll examine the role of the case manager and outline a case study from Apricus that demonstrates the importance of case management integration into workers’ compensation hospital discharge planning.

Responsibilities of a Case Manager

Case managers involved in hospital discharge for workers’ compensation are responsible for developing, implementing and reviewing healthcare plans for an injured employee recovering from a workplace injury. They collaborate with doctors and other medical professionals to coordinate the injured employee’s comprehensive care plan. Their tasks can include:

  • Assessing the injured employee's medical status and creating a case management plan to facilitate the best possible recovery
  • Coordinating care, including transition of care from hospital to home and ensuring follow-up appointments are scheduled
  • Providing ongoing support and education to the injured employee and their family members to engage them in their recovery
  • Advocating for the injured employee and facilitating ongoing communication between all involved parties to ensure prompt delivery of all health care needs

Case managers are trained to handle the complex dynamics of workers’ compensation hospital discharge planning. This can include, securing the initial discharge orders, maintaining frequent contact with the injured employee’s treatment team and working closely with a specialty network, like Apricus, to coordinate product and service referrals and identify any specific requirements for the patient once they leave the hospital.

The following case study illustrates the complexities of hospital discharge planning, and the potential for readmission in catastrophic cases. This case describes the process of injured employee care and problem resolution as approached by the case manager and the Apricus care coordinator.

Case Study

A 29-year-old male employee was injured on the job in a motor vehicle pinning accident. The injured employee suffered a catastrophic injury and was diagnosed with the following:

  • Crushed pelvis
  • Crush injury/fractures to lumbar/sacral spine
  • Massive internal trauma and vascular dissection

The injured employee remained hospitalized for four and a half months due to the extreme injuries sustained and a major complication associated with a non-healing open wound that further delayed his final discharge.

In preparing for the injured employee’s initial discharge from the hospital, the case manager maintained frequent contact with the injured employee, his wife, hospital personnel and treatment team. The case manager anticipated the injured employee would have numerous discharge needs, including various durable medical equipment (DME) products, home modification, and home health services and began working with the hospital treatment team to secure orders ahead of the injured employee’s expected discharge date.

After securing the initial orders, the case manager contacted Apricus with the referrals and orders. Upon confirmation of receipt, an Apricus care coordinator began communicating with the case manager on the injured employee’s discharge orders. Working as a team the case manager and Apricus care coordinator reviewed pertinent information on the injured employee’s requirements, updates on his condition, coordinated healthcare needs and discussed his anticipated hospital discharge date.

The injured employee’s hospital discharge needs included:

  • Bariatric customized wheelchair
  • Building a wheelchair ramp
  • Bariatric walker
  • Bariatric tub bench
  • Home health
  • Home physical therapy/occupational therapy
  • Wound care services
  • IV infusion services

The care coordinator went to work securing the needed products and services. While orders came in piece by piece leading up to the injured employee’s discharge date, even last-minute orders were successfully fulfilled by the care coordinator before the injured employee returned home. After a nearly four-and-a-half-month hospitalization, the injured employee was able to safely discharge home with his needed supplies and resources in place to begin his next phase of recovery.

Unfortunately, after just two weeks of being discharged from the hospital a specialized wound care RN noticed abnormal wound drainage and swelling on the injured employee. The findings were communicated to the internal medicine/trauma team and case manager. The employee was immediately sent to the emergency room for a thorough medical diagnostic examination and was admitted for an additional week’s stay in the hospital due to early-stage sepsis, a potentially life-threatening condition.

Triggering a second hospital discharge order including:

  • Pick line supplies and specialty antibiotics
  • Continued home health
  • Continued home physical therapy and occupational therapy (expected another month)
  • Wound vac (expected another month)
  • Wheelchair, walker and bed (expected for another 3 months)

By maintaining close contact with the injured employee and Apricus team of providers, further debridement, additional hospitalizations, and a potential intensive care unit (ICU) stay, were all prevented due to the quick action of the nurse and teams involved.

The Apricus Difference

As can be seen from this case, case managers working with care coordinators for specialty services can make a significant difference in an injured employee’s long-term health. With input from all parties involved in hospital discharge planning, the case manager ensured the injured employee received the most appropriate treatment for optimal recovery. The case manager worked with Apricus, the specialty solutions provider, to deliver quality equipment and services to meet all service dates and needs and made sure the injured employee and his wife felt their needs were being addressed and coordinated in a timely manner throughout the process.

When it comes to hospital discharge planning, Apricus offers a one-stop-shop experience for all equipment and services that an injured employee may need to help facilitate their recovery. On a regular basis, Apricus care coordinators work together with case managers to expedite effective hospital discharge referrals and orders for injured employees. At Apricus, care coordinators are trained to make recommendations for equipment and injury-recovery services and provide clinical oversight to a national provider network of services including DME, home health, home modification, diagnostics, transportation, and translation services. Apricus care coordinators are proactive in working with case managers and put the injured employee’s needs first.

To promote the best possible outcome in an injured employee’s journey to recovery, a case manager must be in frequent contact with all involved parties, to ensure timely delivery of the injured employee’s medical needs and ensure a continuous flow of communication between them, the treatment team and the specialty service provider. Having a case manager working directly with a care coordinator to facilitate products and services allows the case manager to focus on the patient. Serving as an advocate by placing the injured employee first not only empowers the employee throughout the process, but also reinforces a “people first” philosophy in workers’ compensation hospital discharge planning.