Case Management Monthly

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1 Best practices and practical solutions Case Management Monthly P4 P7 P8 CMS discharge planning advisory boxes Check out this list of the new CMS discharge planning recommendations. Dealing with bullying coworkers Case managers often must deal with bullying in the workplace. Appointment reminder CMS offers educational materials to help patients transition from the hospital setting, including this tool to help them remember their appointments. From the Director s Desk Ensuring patients will follow discharge instructions is crucial to preventing readmissions. Volume 10 Issue No. 8 August 2013 Complex case Learn how a case manager dealt with a patient s fragile mental state following the Boston Marathon bombings. CMS makes recommendations related to discharge planning Learning objectives Describe the new recommendations for discharge planning outlined by CMS Identify strategies to incorporate these best practice recommendations into the discharge planning and transition process CMS has some ideas on how your organization should handle discharge planning. In May, the agency included a series of recommendations related to discharge planning as part of an update to a section on discharge planning in its State Operations Manual. While these suggested processes are not binding and surveyors can t penalize an organization if they are not following them, it s noteworthy that they were added at all and your organization should definitely take notice, says Jackie Birmingham, RN, BSN, MS, CMAC, vice president emeritus, Regulatory Monitoring, for Curaspan Health Group in Newton, Mass. Medicare doesn t usually tell people how to do things, she says. They tell people this is what we ll be looking for and lets them decide how to do it. With this in mind, organizations should review the new recommendations and consider implementing them, says Birmingham. Some say that this move by CMS is one part of a more comprehensive approach to providers that has been going on in recent years. I would think that this goes along with both the readmissions reduction Trendspotting CMS revised its discharge recommendations in section of its State Operations Manual Preventable readmissions can be reduced by conducting follow-up calls with patients within hours of discharge. 504 Hospitals are subject to the requirements of Section 504 of the Rehabilitation Act and the Americans with Disabilities Act.

2 This document contains privileged, copyrighted information. If you have not purchased it or are not otherwise entitled to it by agreement with HCPro, any use, disclosure, forwarding, copying, or other communication of the contents is prohibited without permission. editorial advisory board Senior Managing Editor Jay Kumar Jackie Birmingham, RN, BSN, MS, CMAC Vice President Emeritus, Clinical Leadership Curaspan Health Group, Inc. Newton, Mass. Stefani Daniels, RN, MSNA, CMAC, ACM President and Managing Partner Phoenix Medical Management, Inc. Pompano Beach, Fla. Wendy DeVreugd, RN, BSN, PHN, FNP, CCDS, MBA Regional Senior Director of Case Management Kindred Healthcare, Hospital Division, West Region Westminister, Calif. Deborah K. Hale, CCS, CCDS President Administrative Consultant Service, LLC Shawnee, Okla. Robert Marder, MD Practice Director of Quality and Patient Safety The Greeley Company Danvers, Mass. Contributing Editor Kelly Bilodeau Peter C. Moran, RN, C, BSN, MS, CCM Nurse Case Manager Massachusetts General Hospital Boston, Mass. Loretta Olsen, MSN, RN, ACM Director of Case Management Mercy Medical Center North Iowa Mason City, Iowa June Stark, RN, BSN, MEd Director of Case Management, Social Work, and Support Services Tufts Medical Center Boston, Mass. Karen Zander, RN, MS, CMAC, FAAN Principal and Co-Owner The Center for Case Management, Inc. Wellesley, Mass. Case Management Monthly (ISSN: [print]; [online]) is published monthly by HCPro, Inc., 75 Sylvan St., Suite A-101, Danvers, MA Subscription rate: $349/year. Case Management Monthly, P.O. Box 3049, Peabody, MA Copyright 2013 HCPro, Inc. All rights reserved. Printed in the USA. Except where specifically encouraged, no part of this publication may be reproduced, in any form or by any means, without prior written consent of HCPro, Inc., or the Copyright Clearance Center at Please notify us immediately if you have received an unauthorized copy. For editorial comments or questions, call or fax For renewal or subscription information, call customer service at , fax , or Visit our website at com. Occasionally, we make our subscriber list available to selected companies/vendors. If you do not wish to be included on this mailing list, please write to the marketing department at the address above. Opinions expressed are not necessarily those of CMM. Mention of products and services does not constitute endorsement. Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. CMM is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commission trademarks. Quick Hits Online NY bill aims to mandate nurse staffing Proposed legislation in New York aims to increase the number of nurses per patient in the state s acute care hospitals, according to the Elmira Star Gazette. The New York State Nurses Association supports the proposal; the union said members at 57 unionized hospitals last year filed 19,292 separate protests of staffing assignments they considered unsafe. Readmission rates dropping in NJ Efforts in New Jersey to reduce readmission rates are working, down 7.5% since 2010, according to the Star-Ledger. At the end of 2010, 21.6% of hospitalized New Jersey Medicare patients were readmitted 30 days after discharge, but by the end of 2012 the figure had dropped to 19.98%, a 7.5% improvement, according to Healthcare Quality Strategies of East Brunswick, a firm hired to improve the quality and efficiency of New Jersey s Medicare and Medicaid programs. Follow Us Follow and chat with us about all things healthcare compliance, management, and Questions? Comments? Ideas? Contact Senior Managing Editor Jay Kumar at jkumar@hcpro.com or , Ext from the field Medicare doesn t usually tell people how to do things. They tell people this is what we ll be looking for and lets them decide how to do it. Jackie Birmingham, RN, BSN, MS, CMAC I would think that this goes along with both the readmissions reduction program and what we are seeing with accountable care organizations and global payments. Beverly Cunningham, MS, RN stay connected CMM in Your Inbox Sign up for any of our 17 newsletters, covering a variety of healthcare compliance, management, and reimbursement topics, at Don t miss your next issue If it s been more than six months since you purchased or renewed your subscription to Case Management Monthly, be sure to check your envelope for your renewal notice or call customer service at Renew your subscription early to lock in the current price. Relocating? Taking a new job? If you re relocating or taking a new job and would like to continue receiving Case Management Monthly, you are eligible for a free trial subscription. Contact customer serv ice with your moving information at At the time of your call, please share with us the name of your replacement. 2 hcpro.com August HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

3 program and what we are seeing with accountable care organizations and global payments, says Beverly Cunningham, MS, RN, vice president of resource management at Medical City Dallas Hospital. And ultimately the changes reflect an evolving philosophy when it comes to discharge planning. These changes reaffirm that discharge planning is a process, not an event, says Stefani Daniels, RN, MSNA, CMAC, ACM, managing partner at Phoenix Medical Management, Inc., in Pompano Beach, Fla. About the revisions The CMS memorandum that included the new discharge recommendations was released on May 17 and is entitled Revision to State Operations Manual (SOM), Hospital Appendix A - Interpretive Guidelines for 42 CFR , Discharge Planning. In addition to the new blue advisory boxes, the document also revised the wording in the original discharge planning guidelines. But the changes basically just consolidated existing language, they weren t substantive changes to the Conditions of Participation. But the addition of a series of blue advisory boxes containing the new discharge recommendations was noteworthy, says Birmingham. (We ve compiled a list of the recommendations on p. 4.) CMS says it included these recommendations in distinct blue boxes to make it clear to surveyors that these items are not required for hospital compliance but are instead considered resource information designed to help hospitals improve patient outcomes. The recommendations state that hospitals should make discharge planning a priority by doing the following, in addition to other measures: Creating plans for all patients Working as a team when developing and executing discharge plans Helping patients to transition by helping them schedule follow-up appointments Hospitals should also help ensure successful transitions by following up with patients by phone, partnering with postacute care facilities, and giving patients and families additional education tools. One tool recommended by CMS is the Agency for Healthcare Research and Quality document called Taking Care of Myself: A Guide for When I Leave the Hospital. It includes checklists and worksheets to help patients transition. (See a sample of the doctor appointment reminder sheet on p. 8.) By offering tools like this to patients you may help them more clearly remember and follow discharge instructions. Coming into compliance It s possible that many hospitals discharge policies are not yet in line with these CMS recommendations, says Birmingham. There isn t anything surprising in these guidelines, but if case management departments were to really follow the guidelines, it would require adequate staffing, says Cunningham. In addition, following these recommendations would require departments to be more collaborative with the multidisciplinary team in planning for discharges. The first step any organization should take is to compare these new recommendations against their existing policies and practices, even though they aren t required, says Birmingham. Continuing education information Nurses Contact hours for nurses are available, with 2.5 contact hours awarded each quarter: March, June, September, and December. To obtain your contact hours you must: Read each issue of Case Management Monthly within the quarter (e.g., April, May, and June 2013) Successfully complete and submit the quiz offered in the June issue (passing score is 80%) Complete and submit the evaluation Each quarter s enduring continuing nursing education expires after one year. Disclosure statement: The planners and authors of this CNE activity have disclosed no relevant financial relationships with any commercial companies pertaining to this activity. HCPro, Inc., is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or August 2013 hcpro.com 3

4 I d assign one of the ASPEN tags to staff in my case management department who are responsible for discharge planning, she says. Have them look over what s required, what s in the advisory boxes (see below), what your organization is actually doing, and also what your written policies state. One of the more challenging recommendations provided by CMS will be making follow-up phone calls to patients, says Birmingham. It may be difficult for organizations to find the time and dedicate staff to post-discharge calls. In addition, organizations will also have to decide which patients to call, how and when. Then there s the issue of follow-up, Birmingham says. If the caller finds out the patient is having a problem, who is responsible for follow-up? Technically it s not the hospital because the patient has already been discharged. Organizations will need to make the logistics of a post-discharge call program work for their patients, she says. Working with the quality assurance team is essential in this effort. Changing the way organizations operate The bottom line to me is that while many of us are not in an accountable care organization, we must begin to think like one, says Cunningham. She advises taking the following steps: Know the readmission rates for any next level of care providers to whom the hospital refers patients. CMS advisory boxes at a glance Editor s note: We ve compiled a quick list of the new CMS discharge planning recommendations for you to reference. CMS provided these recommendations as best practices, designed to help you improve patient care. Keep in mind, these items are NOT required for compliance and surveyors have been instructed NOT to cite organizations for these items under the Conditions of Participation. But they are suggested best practices and our experts say you should consider implementing these strategies to improve your discharge processes. We ve created an action tip for each recommendation. In some cases, we consolidated similar CMS recommendations into one item. Tip 1: Make sure discharge practices comply with federal civil rights laws CMS says: These interpretive guidelines address hospital discharge requirements under the Medicare statute and regulations. However, hospitals should be aware that, as entities receiving federal financial assistance (including Medicaid and Medicare payments) and public accommodations, they are subject to the requirements of Section 504 of the Rehabilitation Act and the Americans with Disabilities Act. These statutes and their implementing regulations require that covered entities administer their services, programs, and activities in the most integrated setting appropriate to individuals with disabilities and prohibit covered entities from utilizing criteria or methods of administration that lead to discrimination. CMS does not interpret or enforce these requirements. However, hospitals should ensure that their discharge practices comply with applicable federal civil rights laws and do not lead to needless segregation. Tip 2: Use a shortened discharge process in some cases CMS says: Hospitals might consider utilizing, on a voluntary basis, an abbreviated post-hospital planning process for certain categories of outpatients, such as patients discharged from observation services, from same-day surgery (including invasive procedures see the definition of surgery in the guidance for the surgical services CoP), and for certain categories of emergency department discharges. Given the increasing complexity of services offered in the outpatient setting, many of the same concerns for effective post-hospital care coordination arise as for inpatients. Tip 3: Discharge planning should be a collaborative process CMS says: It would be advisable for the hospital to develop its discharge planning policies and procedures with input from the hospital s medical staff prior to review and approval by the governing body. Hospitals are also encouraged to obtain input from: 4 hcpro.com August HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

5 Align only with next level of care providers that offer the best post-hospital care, including managing readmissions. Ensure a comprehensive discharge planning program, identifying the roles of case management professionals. For example, determine what an RN case manager does versus what a social work case manager does. Not only should the department identify the roles, but the multidisciplinary team must also know those roles. Develop strong collaboration with the hospital multidisciplinary team, including effective (and that word really is the key) daily rounding on patients. Short, concise, effective walking rounds are best practice. Ensure that everyone who needs, and has the benefit for next level of care provided, can receive it. Place special focus on patients being sent home with no follow-up care. Often these patients need at least one visit from home care for medication reconciliation. While it may take some work to bring your organization into compliance, doing so will ultimately be beneficial, says Birmingham. I think if organizations follow these recommendations, they are going to improve their discharge planning process, she says. I think their readmission rate will be positively affected. The value of the case management department will be enhanced. H Other healthcare facilities and professionals who provide care to discharged patients, including but not limited to: nursing homes/skilled nursing facilities, home health agencies, primary care physicians and clinics, etc. Patients and patient advocacy groups Tip 4: Document refusals CMS says: If a patient exercises the right to refuse to participate in discharge planning or to implement a discharge plan, documentation of the refusal is recommended. CMS suggests the same documentation if a patient refuses to participate in the discharge planning evaluation or if the patient decides against participating in discharge planning or implementing a discharge plan. Tip 5: Create discharge plans for all patients CMS says: Given the high level of readmissions that hospitals experience, a hospital would be well advised to assume that every inpatient requires a discharge plan to reduce the risk of adverse health consequences postdischarge. Providing a discharge plan for every inpatient means the hospital avoids the problems that result if it utilizes a screening process that fails to predict adequately which patients need a discharge plan to avoid adverse consequences. This does not mean that every discharge plan will be equally detailed or complex; some may be comparatively simple, for example, focusing on clear instructions for self-care for patients whose post-care needs may be readily met in their home environment. On the other hand, other patients may have complex needs for care after discharge. It is common for many patients to be discharged with a need for numerous ongoing services/therapies, such as intravenous (IV) medications, intensive physical and occupational therapy, remote monitoring, wound care, etc. The key is that the discharge plan must reflect a thorough evaluation of the patient s post-hospital care needs and must address the needs identified. Tip 6: Form partnerships with postacute facilities CMS says: Although not required under the regulations, hospitals would be well advised to develop collaborative partnerships with post-hospital care providers to improve transitions of care that might support better patient outcomes. This includes not only skilled nursing facilities and nursing facilities, but also providers of community-based services. For example, Centers for Independent Living (CIL) and Aging and Disability Resource Centers (ADRC) are resources for community-based services and housing available to persons with disabilities and older adults. Hospitals can find local CILs at and ADRCs and other resources at php?page=homepage Tip 7: Give patients/families a discharge planning tool to aid compliance CMS says: Providing a discharge planning tool to patients and their family or other support persons may help to reinforce 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or August 2013 hcpro.com 5

6 CMS advisory boxes at a glance (cont.) the discharge plan. Use of the tools may encourage patients participation in developing the plan as well as provide them an easy-to-follow guide to prepare them for a successful transition from the hospital. The tool should be given to patients on admission, reviewed throughout their stay, and updated prior to discharge. Examples of available tools include: Medicare s Your Discharge Planning Checklist (available at Agency for Healthcare Research and Quality s (AHRQ) Taking Care of Myself: A Guide For When I Leave the Hospital (available at guide.pdf) Consumers Advancing Patient Safety (CAPS) Taking Charge of Your Healthcare: Your Path to Being an Empowered Patient Toolkit (available at org/page/transtoolkit) Tip 8: Use a multidisciplinary team approach to discharge planning and discharge planning evaluation A well-designed discharge planning evaluation process uses a multidisciplinary team approach. Team members may include representatives from nursing, case management, social work, medical staff, pharmacy, physical therapy, occupational therapy, respiratory therapy, dietary, and other healthcare professionals involved with the patient s care. The team approach helps to ensure that all of the patient s post-discharge care needs are identified so that they can be taken into consideration when developing the evaluation. CMS says the same multidisciplinary approach, using the same team members, should be used for the discharge planning process. Tip 9: Take action to improve transitions such as making follow-up phone calls CMS says: Additional actions hospitals might consider taking to improve the patient s post-discharge care transition: Scheduling follow-up appointments with the patient s primary care physician/practitioner and in-home providers of service as applicable Filling prescriptions prior to discharge If applicable, arranging remote monitoring technologies, e.g., pulse oximetry and daily weights for congestive heart failure (CHF) patients; pulse and blood pressure monitoring for cardiac patients; and blood glucose levels for diabetic patients Follow-up phone calls within hours by the hospital to the patient after discharge The communication with the patient to ensure implementation of the discharge plan does not stop at discharge. An initiative showing significant success in reducing preventable readmissions involves the hospital contacting the patient by phone in the first hours after discharge. The phone contact provides an opportunity for the patient to pose questions and for the hospital to address any confusion related to medications, diet, activity, etc., and to reinforce the education/ instruction that took place in the hospital prior to discharge. Tip 10: Give patients additional resources CMS says: Hospitals may also refer patients and their families to the Nursing Home Compare and Home Health Compare websites for additional information regarding Medicare-certified skilled nursing facilities and home health agencies, as well as Medicaid-participating nursing facilities. The data on the Nursing Home Compare website include an overall performance rating, nursing home characteristics, performance on quality measures, inspection results, and nursing staff information. Tip 11: Schedule post-discharge appointments for patients CMS says: Scheduling of follow-up appointments for ambulatory care services by the hospital prior to discharge has been found to be an effective tool to ensure prompt follow-up and reduce the likelihood of a preventable readmission. This follow-up visit shortly after discharge provides an opportunity for the patient to address any issues or concerns experienced after the inpatient stay. It also provides an opportunity for the primary care physician or practitioner to review and reinforce the post-hospital plan of care with the patient, for rehabilitation therapy to begin in a timely manner, to clarify any concerns related to medication reconciliation or other adjustments to the patient s pre-hospital regimen, etc. 6 hcpro.com August HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

7 Quick tip Combat disruptive coworkers, break the bullying cycle Learning objectives Identify the various types of bullying (lateral violence) Describe the extent of bullying in the healthcare workplace Discuss strategies for developing a healthy and safe work environment When many people think of bullying they think of a hulking kid menacing other children in the school yard. But bullying doesn t end with graduation it often moves right into the workplace. Bullying is a pattern of behavior that may include name calling, unfair assignments, shunning, or criticism that undermines the victim s self-esteem, according to Kathleen Bartholomew, RN, MN, an expert on hospital culture and author of the HCPro book, Ending Nurse-to-Nurse Hostility. You can be bullied by a superior, but what s also common is horizontal or lateral bullying, which occurs between coworkers. Case managers may experience bullying themselves, says Bartholomew, but it s more likely they will be in a position to witness it among nursing staff. Below we ll discuss how to recognize a problem and how to respond if you are being bullied or witness bullying in action. Bullying on the upswing In an era when healthcare budgets are slim, and case managers and nursing staff are often overtaxed with high caseloads, bullying seems to be on the rise, says Bartholomew. Every day nurses are asked to do more with less. Case managers are asked to do more with less, she says. Bullying may be more likely to happen in environments where people are stressed and fuses are short. Programs to educate hospital staff on topics like bullying are also being cut, Bartholomew says. This means case managers and other workers are likely not getting trained on how to recognize and prevent bullying. So what is bullying? Bullying comes in many forms. It can be overt or subtle, says Bartholomew. Overt bullying may include name calling, backstabbing, intimidation, shouting, gossip, and blaming. But bullying can also be more subtle and include unfair assignments, sarcasm, eye-rolling, ignoring someone, or refusing to work with someone. And bullying can take a toll. Victims might experience stress, depression, or anxiety, says Bartholomew. They are often unhappy with their jobs and might think of leaving. Sometimes the stress of bullying can even make people sick, causing headaches, digestive problems, and high blood pressure, or trigger allergies, asthma, or other conditions. How to handle hostility When it comes to managing a bully, speaking up is often the best option, even before contacting your manager, says Bartholomew. The first and often most effective step is to say what you see. Sometimes identifying bullying and rude behavior and pointing it out is enough to stop it, says Bartholomew. Organization leaders play a big role in this issue. Leaders within the organization should work to establish zero tolerance policies for disrespectful or harmful behavior such as negativity or gossip. They also have a role in modeling healthy communication, Bartholomew says. Case managers are in a good position to intervene when it comes to bullying as they re just enough outside the fray to see things objectively. But often their first inclination is to steer clear of the conflict. They might say, It s none of my business. It s not my problem, says Bartholomew. But that s not the right attitude, because ultimately bullying is everyone s problem. Not only can bullying can create a negative culture at the organization, it can also compromise patient safety. So if you see it, speak up, she says. It may be a difficult thing to do, but ultimately it s what s best for the organization and its patients. H 2013 HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or August 2013 hcpro.com 7

8 Sample form Helping patients transition by offering easy-to-use tools CMS has recommended a number of educational materials to help patients transition from the hospital setting. One of those documents is called Taking Care of Myself: A Guide for When I Leave the Hospital, which was created by the Agency for Healthcare Research and Quality ( It contains several helpful tools for patients, including charts indicating when and why they are taking various medications. It also includes the tool below, which helps patients remember scheduled appointments with their physicians and gives them space to write any questions they may have so they don t forget them. H When are my next appointments? When are my next appointments? Day Time Doctor s name Address Date Specialty Reason for appointment Doctor s phone number Questions for my appointment Check any of the boxes below and write notes to remember what to discuss with your doctor. I have questions about: My medicines My test results My pain Feeling stressed Other questions or concerns 8 hcpro.com August HCPro, Inc. For permission to reproduce part or all of this newsletter for external distribution or use in educational packets, contact the Copyright Clearance Center at copyright.com or

9 From the Director s Desk Gaining discharge compliance from patients by Loretta Olsen, RN, MSN, ACM The doctor is making rounds and writes the order to discharge the patient. As soon as the physician walks out of the room, the patient calls his family to come pick him up, even though the doctor just said it will take the nurse a while to get the paperwork completed. It is like the patient is afraid if he doesn t hurry, someone in the hospital will change their mind and he will have to stay another day. Has this ever happened at your hospital? The nurse then comes in with the discharge instructions, reading through the instructions and explaining the new medications to the patient and what medications he should no longer take. The patient nods his head as though he understands. The nurse is explaining the new diet and activity, and just as with the medications, the patient is nodding his head like he understands. The nurse then says, You need to sign here and I will make a copy for you to take home. Then the nurse asks the patient if he has any other questions, to which he responds, No, I understand. The patient is discharged and 24 hours later is back in the ER. He took a double dose of his new medications because he didn t realize he was supposed to cut the pill in half. Plus he continued to take the medications that he had been told to discontinue. What went wrong? Scenarios like this are becoming more common. Why? One reason is that patients typically are having shorter lengths of stay. Because of this, the timeliness of discharge education becomes more crucial. If we know that timely discharge education is so crucial, why is it not common practice in most hospitals? For one, nurses have more critically ill patients. In addition, case managers are facing higher patient ratios due to budget constraints. Plus, I suspect that discharge education and instructions are not always taken as seriously as they should be. Is discharge education seen as a high priority at your facility, or is it put off until the next shift? Often it s not until just before we know the patient is being discharged that there is a rush to provide discharge education. Ideally, discharge education and instructions should be an interdisciplinary process that begins at admission along with the discharge planning. It is everyone s respon sibility. We need to instill in patients and families how important it is for them to understand their disease and their medications, and to follow the discharge plan. We need to teach patients and families to say stop or time out if they do not understand something. Clinicians also need to consistently use the teachback method, asking patients to repeat information back to them as they go. This can help eliminate the nodding up and down of heads when the patient and family really do not understand. We cannot wait until the patient is walking out the door to provide discharge education and instructions. When this topic is brought up, healthcare providers respond with Well, everyone knows that. True, most healthcare workers know that, but is it being practiced? If not, we will see a continual lack of quality in patient care as well as stagnant or even rising readmission rates. H Editor s note Olsen is the director of case management at Mercy Medical Center North Iowa in Mason City....Just ring for the nurse if you d like more patient education materials... A supplement to Case Management Monthly August 2013

10 Complex Case Responding to care challenges following the tragic bombings in Boston Author s note: The April 15 Boston Marathon bombings resulted in three deaths and injuries to more than 200 victims. The city of Boston and its multiple medical centers responded in a rapid, outstanding manner to this terrorist attack by accepting and treating the severely injured trauma victims from the bombing site. Many of the patients presented with extensive injuries that many of the healthcare providers had never seen before. Case managers also faced unique patient care and placement issues. The case study below is an example of one of these unique cases. To protect the privacy of this patient, identifying information has been changed. After bombs go off at the finish line of the Boston Marathon, many apartment buildings near the bombing site are damaged. Tenants are evacuated along the main street near the finish line. Among these displaced individuals is Andrew Warren, 79, who rarely leaves his apartment. When the evacuations of his apartment building begin, Andrew suffers an acute episode of anxiety and is brought to a local hospital, which has also received some of the severe trauma cases resulting from the bombing. Upon arrival to the ED, Andrew s anxiety escalates, requiring a psychiatric consult to prescribe a course of treatment. Andrew is also complaining of ringing and decreased hearing in both ears secondary to the bombings and a migraine-like headache. His vital signs reveal elevated blood pressure and he complains of a slight pressure in his chest. Because of the extreme nature of the events that triggered his health problems, Andrew is admitted to a medical unit. His medical problems resolve over the next two days, but his acute anxiety continues, becoming his primary diagnosis. Andrew s mental state is fragile, as his sudden displacement from his home is a continual source of anxiety for him. It is clear to his medical case manager how unstable he is. Compounding the problem is the constant TV news updates on the bombings and his knowledge that some of the bombing victims are in the same hospital. Andrew s anxiety is a reflection of what other Bostonians are feeling. The home that he knew as being so safe now no longer holds that feeling. With all the terrorist activity that has happened in the past in other locations, Andrew has always hoped that his city was immune. Now he knows it isn t and his worst fears have come true. He feels vulnerable and alone, contributing to his lasting anxiety and uncontrollable hypertension. The medical case manager is moved by this case and contacts her manager for support with the discharge plan. Because of Andrew s condition, the case manager wants him to receive care beyond the hospital. She has several area SNFs screen Andrew for placement. However, their assessments conclude that Andrew does not meet the level of care required. Still feeling strongly that a SNF is the best discharge plan, the case manager asks two of the SNFs to do her a favor and accept the patient. Both decline. The case manager s next step is to identify Bostonbased housing sites that have been set up for those displaced from their homes by the bombings. She carefully assesses each one to determine whether any would be safe for this patient and able to meet his discharge needs. She remains dissatisfied until she comes up with an idea. She will find out where the people who lived in Andrew s building have been placed. Together with the social worker, they research all the special services and resources that have been set up by the city of Boston. It takes a day, but the group is located. The discharge plan is presented to Andrew. He does gain some reassurance once he knows that he will be housed near his neighbors. His acute condition continues for two more days and seems to resolve the day the last bombing suspect is caught. Andrew is discharged the next day and the plan proves to be successful. Ten days after the bombing, the street is open and Andrew and the other displaced residents are allowed to return to their homes. H CMM, PO Box 3049, Peabody, MA Telephone Fax