Before the pandemic, Elliot Hospital case managers would rarely see a patient who had been roomed overnight in the Emergency Department while waiting for a bed. These days it’s common for a dozen or more patients to be standing by for case management to ensure a safe discharge plan or for an inpatient bed to become available.


Case managers on the Care Coordination team are responsible for assessing a patient’s health needs for the day and goals for their stay, as well as ensuring a safe and effective discharge plan to mitigate delays in care. In addition, nurse case managers, utilization review nurses and Master’s prepared social workers, identify a patient’s Social Determinants of Health (SDOH) to prevent avoidable readmissions and ensure community support is accessible, including transportation, food and medication.


“We have more and more patients during the pandemic who don’t have a place to go because of increasingly limited resources – nursing homes, assisted living facilities, group homes, acute rehab facilities and shelters often not able to take COVID patients; facilities closing units because they’re short-staffed or others without the ability to isolate patients in private rooms,” says Margaret Foley, RN, Director of Care Coordination. “Members of our team need to be committed to their job, caring for patients and their families. They almost have to be detectives, quickly gaining a patient’s trust and understanding their needs, to determine the best plan for their success after being discharged.”


On any given day, case managers might be tasked with beginning the lengthy guardianship process for an elderly patient to be placed in a long-term care facility; assisting a patient who needs medical treatment for substance abuse disorder; finding a place to stay for a homeless patient who also has COVID; addressing advance care directives or end-of-life needs for a patient or assuring an acute patient gets a bed in the hospital as quickly as possible.


All of this at a time when resources admittedly are limited.


“Patients who are acute are still coming to the Emergency Department, but we can’t discharge patients who are here because of minimal community support being available to them,” Foley says. “It’s not that the community doesn’t want to help – they just may not have the resources.”


Two years into the pandemic, Foley says she now communicates regularly with senior leadership “to see what we can do differently each day to meet the needs of our patients and our community.” The interdisciplinary care coordination team also continuously communicates and collaborates with community partners and the state.


“Everyone is as busy as the next,” she says. “The key is communicating, collaborating and even bargaining.”


Certainly, the success stories are what keep everyone moving forward.


For instance, Sally Sites, RN, manager of care coordination, says recently a local nursing facility agreed to begin taking patients from Elliot Hospital who need long term nursing care but are still awaiting the state to get Medicaid in place for them.


“This is a financial risk for the facility but an excellent option for our non-acute patients to have a safe discharge plan,” she says. “It frees up the much-needed acute care beds for our emergency room patients who are waiting and helps our most vulnerable patients be safe.”


Being a clinician in a hospital setting, Foley says, “we have the privilege of meeting patients where they’re at, entering into their world and understanding what they need at their most vulnerable time so we can create a plan for when they leave here that will help them be most successful.”


As she put it, “When we hear back from them or their family members how well one of our patients is doing because of that plan, it makes all we do worthwhile.”