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April 2013

Volume 1, Issue 4

Case Management Rounds The Evolving Role of the Transitional Case Manager Who will bridge the gap between care coordination in the hospital, skilled nursing facility, physician's offices, clinics, and medical homes? What measures has to be implemented to prevent patients from returning to the emergency room or to the acute care hospital shortly after the initial hospital admission? Who will be the liaison between the patient and the health care team to identify issues with the customized treatment plan? The answer to all three of these questions is… The Transitional Case Manager! The health care industry is catching on fast to the need to have someone manage the patient in every step of their treatment plan. Even with assigned case managers at every health care facility to manage the patient's care at that respective site, there must be someone to manage the care between the respective settings. Someone has to stand in the gaps to ensure that there is a smooth transition from one level of care to the next. Thus

the creation of the Transitional Case Manager. The transitional case manager may be employed by the hospital to bridge the gaps to prevent hospital readmissions. The facility who creates this position is forward thinking and financially savvy. There are certain hospital diagnosis that will not be reimbursed to the hospital if the patient returns within 30 days with the same diagnosis that he/ she was discharged with. The transitional case manager can earn his/her annual salary just by appropriately case managing one chronic patient who historically returns to the hospital on a frequent basis. Whether the transitional case manager is employed by the hospital or outside of the acute care setting, it is important for open communication to occur with any and all case managers who are managing the chronically ill patients. The transitional care manager is positioned to be able to identify potential or actually non compliance with the plan of care. He/she should

then implement an action plan to correct the problem. Contact with the responsible staff on the health care team can create an optimal outcome for the patient. Patients may not totally understand their treatment plan or the discharge summary prior to discharge home. A follow up call from the transitional case manager within 24-72 hours may identify the need to again explain the plan to the patient and or the family members. Studies have shown that up to 85 percent of all patients are illiterate. They are embarrassed to let this be known and they will pretend to understand the written instructions. Have the patients and /or their family members to verbally repeat back the planned treatment. This verbalization will reinforce the patient's understanding of the planned care. The transitional care case manager may have the responsibility of coordinating care outside of the hospital to ensure that the patient follow up with their primary care physician or designated specialist post dis-

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Case Management Rounds

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Healthcare Headlines cont’d charge. The transitional care manager must possess the skills of a traditional case manager and be able to think globally about the patient's care coordination. A case manager who is a critical thinker, an effective problem solver and who provides the appropriate resources to connect the patient with, will be the best person to fulfill the role of transitional

Meet Mary Frances Fields- elite Case Management Instructor

case manager. There are a number of listings in the job engines for transitional case managers to coordinate care along the continuum. If you are interested‌Go For IT!!!. This is a new playing field for case managers. Be confident that you can be a successful care coordinator during transitions.


Instructors Corner Mary Frances has over 30 years of nursing experience which includes medical-surgical, emergency department, nursing instructor, public health department, utilization management, and Case Management. Mary Frances is a registered nurse with a Bachelor of Science Degree from University of North Alabama and a Master of Science Degree in Nursing from the University of Phoenix. Mary Frances' outstanding case management experience includes extensive work with active duty military soldiers in their transition back into the community with their families. She has assisted military staff with behavioral issues which included post traumatic stress disease (PTSD). Her passion for this

work has created a seamless return to the home for many military personnel. Mary Frances has been employed with the Mississippi Department of Health where she was a strong advocate for women and children. She coordinated preventive health program measures for eleven counties throughout the state. She developed, implemented, and coordinated the nursing practice standards for the preventive health program. Mary Frances is professionally affiliated with the American Nursing Association, Mississippi Nursing Association, Case Management Association, and Mississippi Public Health Association. Mary Frances is an ex-

pert in her field of practice. She has a passion for speaking up for the patient in the advocacy role. She takes pleasure in openly communicating and embracing the entire healthcare team. She is an excellent teacher, mentor, and care coordinator.

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Volume 1, Issue 4

Along the Continuum of Care, What Every Case Manager Must Know Author Pauline Sanders, RN, MBA, CPHRM, CCM releases her first book June 2013. Pre-order your copy today! And save 15%

Upcoming Classes Case Management BootCamp, June 13-15, 2013 Los Angeles, CA. 21.5 Contact Hours

Case Management BootCamp, July 30—Aug. 1, 2013 Oakland, CA 21.5 Contact Hours

Case Management Rounds  

elite Case Management presents Case Management Rounds, a monthly newsletter to educate, empower and inspire Case Managers and healthcare pro...