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More Resources for Staff, Better Care for Patients

GettyImages-915090424.jpgBeing in the hospital is stressful and for many of our patients, it’s the transition to home and aftercare that gives pause. In the hospital, there’s someone by your side every day helping you understand what’s happening, why, and what you can expect next. The role of the inpatient care management team is to make the transition home easier, and their job starts as soon as a patient checks in. Care management at EMHS is evolving to ensure that all of our patients receive the right level of care and support.

The new care management model relies on EMHS as a truly integrated system, showing patients and their families just how connected we are, with how smoothly they can navigate from inpatient to outpatient care, and meet their personal goals. “It’s really exciting to be a part of a group like this. The blessing is that we’re in a healthcare system with so much to offer, not just great inpatient and ambulatory care, but great skilled nursing services, physical therapy, and homecare. We have the seeds planted for everything it takes to make our patients successful; we just needed to learn how to leverage that together,” said Beth Rolfe, RN, NE, BC, EMHS interim vice president of Integrated Care Management, and VNA Home Health Hospice vice president of Nursing and Patient Care Services.

The group Beth refers to includes team members from every member organization, working together to look for a solution from a system perspective rather than as individual organizations. “Early on we identified core values that would help us bring together our diverse organizations and focus on what’s best for our patients. It’s a lot of work, sometimes, to set aside how you’ve always done something and be open to something new, but as a team we were able to keep coming back to what mattered: the patients and their families receiving the support and care they need and deserve.”

One big change was recognizing that not all patients require the same level of hands-on assistance when it comes to discharge planning. “Part of this is really ensuring that staff are working to the top of their license, we want to ensure that we have the right people doing the right tasks and that our patients with complex care needs—during and after their stay—are set up for success,” said Beth.

A change that will alleviate some of the staffing issues that we’ve faced in the past, ensuring clinical staff and social workers are focused where they are needed, is the creation of the integrated care management resource center. Comprised of licensed and non-licensed associates, the resource center is staffed 12 hours a day, seven days a week and supports all of our member organizations. The new resource center and longer hours increases access for patients and allows them to go home faster.

Through the resource center, care assistants will continue to provide support for non-complex patients. Bedside nurses will provide a consult to the resource center, and staff will provide clinical and resource support for non-complex cases. This could be something like ensuring that patients have transportation home, if their family is unavailable, or ensuring that their primary care follow-up appointment is set up before they leave the hospital.

Licensed personnel at the resource center including registered nurses and licensed clinical social workers will be staffed at all times. They will assist in more complex cases where a care manager or social worker is needed, but there isn’t staff available at the member organization. For smaller facilities, this will alleviate the burden on staff to feel they always need to be available. For patients, it means they will be able to leave the hospital sooner and improving the patient experience. Truly a win-win for staff and patients.