1. Julia Karnemaat, RN, BS, CCM Kari Wildner, LMSW, LCSW
Navigating Muddy Waters: Case Manager Collaboration Across the Spectrum
Julia Karnemaat, RN, BS, CCM
Kari Wildner, LMSW, LCSW

2. The importance of coordination of care with the interprofessional team.
Exploring challenges and barriers to complex care planning.
Communication strategies to keeping everyone informed and establishing a patient centered plan of care.

3. Who’s in the water?

4. Acute hospital stay
Community care setting
Long term care setting
Skilled nursing and rehab
Primary Care

6. What are our navigational beacons?

7. Service of the Poor
Reverence
Integrity
Wisdom
Creativity
Dedication

8. Cultural Competency
Meeting the patient where they are at
Patient Engagement!
Knowing yourself

9. Assessing the patient’s needs: Who needs a life preserver?

10. Initial Risk Stratification
LACE Tool
Care Management Assessment
Substance Abuse Assessment
Palliative Care Assessment

11. What tools are YOU using?

13. How do we communicate the patient’s needs throughout all levels of care?
In the community
During hospitalization
At time of transition
Advance Directives

14. Team Strategies and Tools to Enhance Performance and Patient Safety
TeamSTEPPS
Team Strategies and Tools to Enhance Performance and Patient Safety

16. Community Health Workers PCP Community Health Workers
Navigators Liaisons
Navigators Liaisons
PCP
Community Health Workers
PCP
Community Health Workers
Patient
Inpatient Case Mgr
Health Ins. Case Mgrs.
Inpatient Case Mgr
Health Ins. Case Mgrs.
Communication with individuals outside the hospital who are involved with patients’ care: Who’s at the center of care?
Who else might you want to communicate with about a patient’s admission?
Preferred method of communication?
SNF
Family/Legal Guardian

17. SBAR Call-outs Checkbacks IPASStheBATON Briefs Huddles Debriefing
AHRQ Interventions
SBAR
Call-outs
Checkbacks
IPASStheBATON
Briefs
Huddles
Debriefing

18. HIPAA
How does it affect our ability to communicate with outside entities?

20. Multi-Party Release form Mental Health & Substance Abuse Services

21. Barriers and Strategies to Overcome: Navigating rocks in the water

22. Psychosocial/Financial
Barriers
System
Logistical
Psychosocial/Financial
(insert Silo Barrier image)

23. Strategies
Visual
Take home tools
Multicultural approach
Levels of teaching/incorporating family
Patient Engagement

24. The Spirit of Motivational Interviewing

25. An Underwater Moment

26. TEAMWORK
Physicians
Nursing
Social Work
Therapies (PT, OT, SLP, RT)
Dietician
Spiritual Care
Palliative Care
Ethics

27. Team Communication
IDT Rounding
Brown Bag/Lunch and learns
Team Briefing
Debriefings
Complex Care Huddle

28. What’s on the Horizon?
Telehealth
Mobile Apps
Telemedicine

29. I PASS the BATON
I Introduce yourself and your role/job
P Patient-Name, identifiers, age, sex, location
A Assessment-Presenting chief complaint, vitals, Sx, Dx
S Situation-Current status/circumstance, code status, level of uncertainty, recent changes, responses to Tx
S Safety Concerns-Critical lab values/reports, socioeconomic factors, allergies, falls, isolation, etc.

30. I PASS the BATON
B Background-co morbidities, previous episodes, current meds, fam Hx
A Actions-what actions were taken or are required? Provide brief rationale
T Timing-level of urgency and explicit timing and prioritization of actions
O Ownership-who is responsible on team? Include Pt/fam responsibilities
N Next-What will happen next? Anticipated changes? What is the plan? Backup plan?

31. Putting IPASStheBATON into practice
Walk through communication/coordination of care example

32. Case Study #1
A 54 yo male admitted from the community w/chest pain and is in need of emergent heart cath. He coded, was intubated, and transferred to ICU. He was found to have severe multi-vessel disease with low EF 20-25%. After day #3 on vent, he was successfully extubated and is now encephalopathic and has been transferred to general med floor w/1:1 sitter in place
DISCLOSURE: This case was not taken from any particular patient or case, but is a hypothetical example from collective experiences

33. Case Study #1 (continued)
He reported previously living alone and working part time. He is uninsured/not eligible for Medicare. No known NOK or DPOA for health care. Pt’s ID shows a home address. No known mental health or substance abuse hx. He has no PCP and has not had any access for health care in the last 20+ years.
PT, OT, ST (Cognitive)
Eating/Bowel fx?
Due Diligence…Ethics consult?

34. Barriers
Strategies

35. Case Study #2
A 50 yo woman found down at her AFC home. Hx of schizophrenia and substance abuse, 2ppd smoking hx in the setting of COPD, CKD, and DM. Was found to be in acute hypoxic respiratory failure and was put on HFO2. Complications during her hospital stay accelerated her CKD to ESRD and she began HD.

36. Case Study #2 (continued)
Prior to hospitalization, she was her own legal guardian and had CMH services. Now mentation is waxing and waning, pulling at lines, agitated and “non-compliant”. AFC home cannot take her back and she is refusing Tx and medications, stating, “No, I don’t want that.” Per CMH, she has one adult dtr/only known NOK and who has limited contact with pt. At this time dtr is saying, “do everything for my mother.”
Remember: WHO/WHAT/WHY not end result/disposition
Consider Psych consult---capacity v. competency
Complex Care Huddle

37. Barriers
Strategies

38. Call to Action/Reflections
(Reference statistics about hospital d/c, coordination of care, communication)
Reference handouts available

39. Take Homes
Utilize evidence based tools when assessing
Identify possibilities for enhanced communication within your interdiscplinary team AND with the interprofessional team
Focus is on patient centered care

40. *add in Reference slide at the end