Texas Health’s Care Transitions Management teams, whose vital work can help lengthen and enhance patients’ lives after their hospital stays, are finding innovative ways to meet formidable COVID-19 challenges.
“We’re in a land we’ve never been in before,” said Clint White, B.S.N., R.N., CCM, director of CTM at Texas Health Harris Methodist Hospital Fort Worth. But that hasn’t stopped them. Teams across the system went into action, finding new ways to manage care from arrival to discharge.
Skyrocketing patient numbers, drastically curtailed contact with patients’ families, new home oxygen management issues, limited availability of beds at skilled nursing facilities and ever-changing community resources are among the challenges, said White and Hazel Edwards, M.S.N., R.N., CCM, ACM, (pictured lower left) who is CTM director at Texas Health Harris Methodist Hospital Hurst-Euless-Bedford.
“Texas Health has always recognized the importance of extending the care continuum outside of the walls of our hospitals for our discharged patients,” said Kirk King, hospital channel chief operating officer. “Our CTMs play an invaluable role in facilitating post-discharge care, and they possess the relationship skills to care for the social and emotional needs of our patients and their families as well as their physical needs.
“Their intimate knowledge of the post-acute care community and their innovative approaches to connecting the patient with the right resource contributes to lowering readmissions and improving outcomes for both our COVID and non-COVID patient population.”
Oxygen needs present challenges
White said that oxygen-dependent patients who needed it temporarily would normally stay at the hospital until it was no longer necessary. But COVID-19 has limited the number of available hospital beds. He and his team joined with MedStar to transport patients in observation status home if their physician approves. Then, medical professionals go to follow up for seven days.
“With COVID, since some of these patients can’t afford follow-up care, we’re doing extensive teaching using nursing staff on how to use a pulse oximeter,” White said. The patients are supplied with pulse oximeters with the Texas Health logo and taught parameters for different oxygen levels — when to call 911 or go to urgent care, how to turn up oxygen and how to call and have the equipment picked up.
At Texas Health Harris Methodist Hospital Cleburne, CTM supervisor Annette Jacobs, B.S.N., R.N.,(picture lower right) and her two-person team are available 24-7 to get patients home from the Emergency Department with oxygen.
“We might have to send someone home at 3 a.m. with oxygen so the Emergency Department can take someone who’s more acute.”
Skilled nursing beds in short supply
White and Edwards both said care transitions managers also are coping with fewer skilled nursing beds in their communities.
“One of the major changes with the pandemic is how we approach routine tasks,” Edwards said. “When patients are ready to be discharged and need a post-acute level of care, pre-COVID we could give them a choice from a lot of availability. Now the availability of beds is first come, first served.”
White said his team checks with skilled nursing facilities daily to find open beds and open COVID-19 beds, working with 86 different facilities.
That step helps get patients to a facility faster. If they made a referral only to find there were no beds, his team would have to look for another facility while the patient waited.
Critical thinking skills
Care transitions managers are accustomed to thinking on their feet. Edwards said her team of 21 works closely with community organizations and government programs to help establish care after discharge for unfunded, undocumented patients when they meet criteria.
“We look for anything we can think of outside the box that will allow patients to safely transition to a safe level of care — to continue their healthcare successfully to prevent readmission,” she said.
White said good care transitions management can improve and even lengthen a patient’s life after they leave the hospital. For example, correctly managing healthcare needs for a patient with congestive heart failure can mean they don’t get worse and return to the hospital sicker than they were when first admitted.
“It’s a big deal,” he said.
Edwards said CTM is a key part of Texas Health’s multidisciplinary healthcare. The managers set patients up for success, fulfilling clinical and social needs as patients transition back into the community, she added.
White said knowing the importance of their work helps his team manage the constant stress and change that come with COVID-19.
“CTMs have always been important, but we’ve been called to step it up even to another level and identify barriers that have never existed in the history of case management,” he said.
(Picture top right: Felicia Badger, M.S.N., R.N., manager of Care Transitions Management, with Clint White, director of CTM and Keke Salazar, B.S.N., R.N., care transitions manager, all at Texas Health Fort Worth.)
By Judy Wiley • Posted February 2, 2021
