Community Case Management – Improving Transitions of Care Since 1995

Purpose:
Goals are to promote increased patient adherence through education, referral to other resources, and intensive care coordination. The program assists patients in utilizing the health care system appropriately through home visits by an Advanced Practice Nurse or Licensed Clinical Social Worker.

Relevance/Significance:
This program focuses on patient safety in the form of reducing unnecessary hospitalizations and emergency department visits. The nurse has the time to spend with each patient; in his or her own environment, that is necessary to avoid poor outcomes associated with rushed interventions by other health care providers. Nurses are able to assist the patient in a wide array of interventions to ensure their safety is a priority.

Strategy and Implementation:
The program was created to assess and manage care of patients are frequent users of the emergency department and hospital by providing home visits and care coordination. This is a unique program that has evolved over 20 years with careful self-monitoring and evaluation. The program's goals are to promote patient engagement through care management and coordination, education and referral to other resources. The program provides home visits to patients by an Advanced Practice Nurse or Licensed Clinical Social Worker to manage individual patients.. Community case managers work closely with primary care providers, other care managers and community agencies to coordinate care. As a unique practice group our mission is to continually seek ways to innovate our care delivery. Our goals include promoting client independence, preventing readmissions and evaluating our effectiveness annually through data collection and review.

Evaluation:
In 2014 patients, who were open to community case management services decreased their visits to the emergency department by 50%, from the previous 3 months, and decreased their visits to the hospital by 46% from the previous 3 months. Data in past years also shows an increase in the hospital's reimbursement rate by 4% for the clients served by community case management.

Implications for Practice:
This is a nurse-led community case management model, in which an assessment is complete in the home including: review of medical history and limited exam, medication review and reconciliation, evaluation of psychosocial status, functional status and limitations, home safety, advance directives.