Precisely what do hospital case managers do?
In episode four of The Senior Soup Podcast, Margie Hackett, Suburban Hospital’s manager of transition care and population health, breaks down the three primary components of hospital case management and a hospital case manager’s job description.
This episode aims to educate aging adults and their families on what to expect during an in-patient hospital stay – from arrival to discharge and post-discharge.
Are you ready to learn the critical function of hospital case management?
Keep reading The Senior Soup‘s essential guide to hospital case managers!
Hospital Case Manager Job Description
- The criteria for a safe hospital discharge
- Preparing yourself for a hospital stay
- Who and what makes up a hospital case management team
- Financial and community resources
- Patient Advocacy
- Supporting your local hospital system
All about hospital case management
Raquel Micit 0:00
Welcome to The Senior Soup Podcast!
My name is Raquel Micit.
Ryan Miner 0:03
And I’m Ryan Miner.
Raquel Micit 0:04
We have a very special Soup of the Day, focusing on hospital case management.
And today’s podcast aims to educate our audience on what to expect during an in-patient hospital stay – anywhere from time of arrival, time of discharge, and really, post-discharge, too.
We feel so honored to have our special guest to spotlight today: Margie Hackett from Suburban Hospital in Bethesda, Maryland.
And Margie is a manager of transitional care and population health.
Hi, Margie!
Case management at a hospital – What do they do?
Margie Hackett 0:36
Hi, how are you, Raquel?
Thank you for having me. And Ryan.
Raquel Micit 0:39
Where we want to start is what is a case management team.
Can you break that down?
Explain the roles.
And really, what do you guys do here?
Margie Hackett 0:48
We’re like other hospitals and a case management team.
There are three main parts to case management inside a hospital.
Hospital Case Managers Are Responsible For Discharge Planning
The first part would be discharge planning.
That’s what most people know about.
- They do an assessment, a screening, and an assessment when people arrive.
- And what kind of needs do they have at home?
- How are they managing at home?
- Who do they live with?
- What’s their insurance?
And a whole lot more.
So they learn that about them and look at the big picture of what’s happening in the hospital or, you know, their health.
- How are their labs?
- Are they recovering fast from their illness?
They’re looking at all those pieces to help plan what this person will need after discharge.
Where will they have to go if they need extra help?
Hospital Utilization Management
And then there’s a piece related to case management and utilization management.
So, utilization usually refers to the cost of health care services.
- They evaluate what this person needs.
- Is their insurance going to cover it?
- What kind of documentation is his insurance need?
- They communicate with the insurance company.
- They also communicate with physicians.
They might help, they might help get authorizations to place in a facility after the hospital, if that’s what they need, or they will help with transfers to other hospitals, home health, that sort of thing.
Transitional Care & Population Health
Then the third part would be transitional care and population health.
No longer are we just responsible for patients in their care, health, and hospital.
We’re also tasked with helping them in the community.
Transitional care – population health – is trying to help the person in the home managing in the home.
- Do they need some self-management techniques on how to manage their chronic condition?
- Do they need help getting their medications?
Those are the three main parts.
There are other case managers as well, though.
The social workers can do discharge planning. But they can also do counseling. They can do placement for behavioral health situations.
There are a lot of pieces to case management.
It’s more than just, ‘Here’s the case; let me manage it.’ Lots of different parts to it.
The Three Essential Components Of A Hospital Case Management Team
Ryan Miner 2:26
Talk us through who comprises a hospital case management team and what are all the working parts and components.
Margie Hackett 2:33
So, it makes me go back to the three elements:
- Discharge Planning
- Utilization Review
- Transitional Care
We all do different aspects for that patient.
You think about a person coming into the hospital. Let’s say they have a problem with congestive heart failure.
What does that look like?
- How did they demonstrate their symptoms?
- Do they need to stay here for one, two, or three days?
- Are they recovering?
- Do they need more time and more labs?
- Or has something changed?
- Did they get a fever?
So nobody ever has one problem when they come to the hospital.
Margie Hackett 3:02
Case management teams are involved in all parts of their stay.
The American Case Management Association Discharge Template
Just having gone through the credited case management program myself, out with the ACMA, one of their phrases (and I wrote it down, so I didn’t forget):
- Plan for the day
- Plan for the stay.
- And plan for the way.
Plan for the Day
So every day, you need to look at what is happening today.
Plan for the Stay
And you want to also plan for the whole stay.
What do we anticipate? We anticipate a discharge date in three days; let’s say; it could be anything.
And if it has to be adjusted, they’ll extend it, or if they feel better and their symptoms are better, they can leave the hospital earlier.
Plan for the Way
And then the last one is, “Plan for the way” – their way outside, their way outside the hospital.
When patients come into the hospital, what are their expectations for what they think they need in the hospital?
Is it, ‘Well, I don’t feel good; you need to keep me till I feel better?’ Well, let’s investigate what it is, right? It’s way more than that.
Well, many people come to the hospital thinking they need to stay here, but sometimes it’s really something that can be managed in the community.
We must be careful about having people in the hospital who can be managed in the community.
If we’re taking up beds for those reasons, then we don’t have beds for those who have to have a hospital level of care.
Somebody comes in the hospital, and it can be treated very quickly in the hospital, in the emergency department, or one day in the hospital, they’re going to go home.
We will ask them to reconnect with their primary care doctor or the specialist and get the care they need in the home.
People need to learn how to manage themselves.
There are a lot of people out there to help guide them with their care after the hospital or even avoid the hospital in the first place.
What can a hospital case manager help me with?
Raquel Micit 4:18
A common topic and goal are to ensure they have a safe discharge so they can continue to thrive at home.
Can you talk to us about what a safe discharge looks like?
Maybe what are some challenges when getting discharged?
Margie Hackett 4:31
Sure, a safe discharge:
Yes, that is the goal of case management – when people leave the hospital, they will go to a safe place or be safe there.
What does that look like?
Safety means they have somebody – a willing, able, and available caregiver. It could be a daughter, a spouse, a mother, whatever it is, whoever that person is.
What kind of help do they need?
They might need just a minor help. It might be somebody checking that they have groceries in their refrigerator.
Do they have what they need from somebody to make a quick trip to the store for them?
To be safe, you have to be able to walk.
Can you walk from your bedroom to your bathroom?
Can you walk from your front door to your bedroom?
If you cannot, maybe you need to have some services in the home to help you.
Maybe you need a private duty aid.
Maybe you need somebody to stay with you at night – because you’re up at night and wondering.
Oh my gosh, I could go so far anywhere, in many different directions, with this.
What Is Transitional Care?
Ryan Miner 5:17
Your focus here at Suburban Hospital is specifically transition care.
Can you walk us through what that means and what that entails?
Margie Hackett 5:24
Care transition is a time when there is excellent discourse – sometimes between what one provider said and then they get to the next provider said.
Let’s say they’re in the hospital, and they transition from the hospital to the home.
But we have all the physicians working in the hospital, all of that discharge instructions.
They need to connect within a week with their provider in the community.
So that transition, that time of transition to the community – connecting with their primary care doctor – is important – so that that primary care doctor knows what happened in the hospital.
They see the patient; they see them face to face; they review the instructions, and they know this kind of work in the community for the person – because that primary care doctor really should know the patient in the community, what they’re, how they’re managing.
But there are so many other transitions:
- The transition from the hospital to home health would be a transition;
- The transition from the hospital to a skilled nursing facility is another;
- And then there’s another one after that because a skilled nursing facility is short-term.
Patients have a transfer from a skilled nursing facility to a home or home with home health.
Each grouping, each place where they have their care, has a different provider often in charge.
That transitional care is the right message – getting to the next level of care, picking up that care, and continuing.
Transition Of Care From The Hospital To A Skilled Nursing Facility
It’s called a lower level of care, whereas a hospital has a higher level of care.
- And as you get out to the community, the skilled nursing facilities are at a lower level.
- Home health is at a lower level.
- Being in the home is lower level, meaning you have to lay people helping you in the home.
Ryan Miner 6:41
You connect people to the next level of care and make sure that they leave – hopefully happier and healthier, and to ensure that the continuum of care – which I love that phrase.
We love discussing how it works, functions and everything you imagine with our current healthcare system is working as it should.
Margie Hackett 7:01
Agree – a continuum of care, for sure.
And people need to realize that.
They need to figure out how to care for themselves – in many ways.
There’s a lot of support to help them – but it comes down to you.
What are you doing to take care of yourself?
People can tell you tons and tons of stuff, but you’re not absorbing it.
If you’re not taking it to heart or maybe making some adjustments that need to be made, you’re going to be right back where you were before.
It’s a challenging situation to be in.
Ryan Miner 7:25
Raquel tells me things every day, and I try to remember them. She reminds me all the time of things.
Raquel Micit 7:30
I’m big on notes; I take notes for everything.
Ryan Miner 7:33
She would have a note from a year ago – what you were doing at what time and it would be accurate.
Margie Hackett 7:38
And she would find it.
That’s my problem. I might not find it.
Ryan Miner 7:41
Well, she would definitely find it, unlike me, who can’t find things.
Raquel Micit 7:44
Receipts!
Ryan Miner 7:44
You need receipts!
Raquel Micit 7:47
So, Margie, you answered a question I would ask you.
I was going to ask how you guys serve as advocates for these patients, but you had already answered that.
Because the thought process that goes through my head is a hospital visit can be a very scary experience for anybody, let alone seniors and aging adults.
I think it’s great that it sounds like you guys set them up not only to continue to thrive when they leave the hospital but to continue to thrive when they’re in the home with non-medical intervention, with medical intervention – anything that they need out there, they need to know that they have a team in place that will help connect the dots.
And I think that can be a challenge sometimes.
The Hospital Case Management Team
Margie Hackett 8:32
They should look at it like a team:
- Their primary care physician is a team.
- There are other specialists are the team.
- The nurses in those offices are part of their team.
But they also need to include their family.
If they have a private case manager, that person is on their team – because there’s also – we didn’t even talk about this part of case management – in the community.
We don’t have that here at Suburban, but there are community case managers always.
Many physician practices have case managers embedded in their offices to help patients navigate care issues unrelated to the hospital.
- And then, there are private case managers;
- Also, social work nurses;
- And lay people doing case management to help with medication management;
- Or how to find the right place to live.
How do you know what kind of care you might need or what kind of senior living building you want to be in?
Maybe you want to be in independent care and are best suited for assisted living care.
So there are a lot of different kinds of case management out there.
Ryan Miner 9:19
That is so true.
Working in health care and formerly home care, and now in mobile primary care with Ennoble Care, when I worked in a position like Raquel.
Although Raquel owns her agency.
Raquel Micit 9:29
Amada Senior Care!
Ryan Miner 9:30
You have to mention it.
Care After Hospital Discharge
Ryan Miner 9:32
I remember the scariest part of someone discharging from a hospital or even a skilled nursing facility is not having enough information to ensure the patient thrives post-discharge.
And I remember one particular discharge that was scary. Somebody was coming out of a skilled nursing facility.
The person did not have any family close by.
He was 92 years old.
They walked him out.
They gave him his bag of clothing, and they gave them the medication list with a medication bag.
No kidding, it was pretty heavy.
And they said, ‘Okay, let us know if you have any questions.’
For me, not being a clinical person and not having a nursing background – that scared me.
I felt so uneasy.
I mean, what do you think about that?
Margie Hackett 10:15
It’s not ideal, that’s for sure; it’s not ideal.
Most times, when people leave skilled nursing facilities, they do; they come out with a big bag of medicines because they’ve already paid for them. So they give them what was left over from the facility with the list.
The medicine names are different than they will get from their pharmacist – at the, you know, the local pharmacy.
They don’t know how to reconcile those two things.
Transition From The Hospital To A Skilled Nursing Facility
Most skilled nursing facilities are sending patients home with home health, so the home health agency will help be that bridge.
Many hospitals are also trying to put in transitional care programs from the SNF – skilled nursing facility – to home health.
So Suburban has not gotten to that part yet.
A lot of the hospitals are doing that bridge as well.
That is really scary.
You think I don’t know why he didn’t get assigned to home health?
Maybe he refused home health, right? He could be somebody who doesn’t want him in his house.
Sometimes we’re our own worst enemy, right?
A hospital or the skilled nursing facility might recommend, say, let’s say, home health, both of them.
And the patient might go, ‘I don’t want anybody in my home,’ or ‘I only want that person who came the last time.’
Well, you can’t guarantee the person you had last time.
‘I don’t want a nurse; I just want PTs.’
You don’t get to choose what you want necessarily.
You have to accept what is recommended and what your insurance company covers.
How they manage these things is really scary for somebody with no insurance.
Ryan Miner 11:22
That’s another podcast where I think we could invoke county and state resources.
Raquel and I deal with that a lot. We try to help people. That’s the goal of this podcast.
Raquel Micit 11:31
Well, yeah – to be a good resource and be able to let people know what’s out there.
You don’t know what you don’t know.
Your Hospital Discharge Papers & Instructions
Margie Hackett 11:37
We talked about a safe discharge plan.
We’re in a hospital; you’re in a hospital.
You have these problems; you’re getting better.
You can tell you’re getting better.
Somebody – maybe you, your family, the doctor, the nurse, the case manager – is worried about you managing at home alone.
You don’t have anybody who lives with you.
Maybe you’ll bring somebody in, but it might not be enough to have some private duty at home.
You might need some extra help.
So if they’re recommending something you’re not interested in, such as a skilled nursing facility, how do you manage that?
I’m here to encourage you to please accept the recommendation of the health care team. They do know what you’re capable of.
If you don’t qualify for a skilled nursing facility, you won’t go there; you will only go if you are eligible.
And if you have that physical need, that will help you get stronger faster, to go home to your own life in your own home after that.
If you’re determined to say, ‘I’m not gonna go to school or facility; I only want to go home,’ they can put some other things in place – but they might not get you back to your pre-physical condition and ability if you don’t take the complete recommendations of the hospital.
So think about it before you say no if somebody has recommended things.
Case managers help find your community resources.
And along that line, if you don’t have the money for it, or you don’t have the insurance coverage for something, sometimes just saying, ‘I still want to do it,’ people will go and look for ways to cover it for you.
There is charity care.
There are some benefits to some services.
But if you say no, nobody knows you’re saying no because of money.
If no is because of money, say, ‘I’d really like to do it, but I don’t know how I’d pay for it.’
Case managers will help you figure that out.
Raquel Micit 13:02
It’s fantastic if you think about it.
Suburban Hospital and many others have put a power team in place to help support people and ensure they continue to thrive and are not alone in this.
You guys are the experts. You guys help educate them on their options.
I, for one, definitely did not know all of these resources we had before getting into this industry.
It’s amazing, and we should all feel very grateful for what the system has put in place.
I think we’ve come a long way
Ryan Miner 13:33
I think so too.
Margie Hackett 13:34
I do as well, for sure.
I’m going to add some more; I told you this.
Raquel Micit 13:37
We love it; keep it coming!
How to plan for a hospital stay
Margie Hackett 13:39
Nobody ever thinks they need the hospital.
So how can you plan for a hospital stay?
- Take care of yourself, all that good stuff, right?
- Eat in moderation.
- Take your medication.
- See your doctor.
- Have a relationship with your doctor, and go regularly. If you have a problem or question, call, don’t wait.
Advocate For Your Self
But also be an advocate for yourself.
If you’re starting to struggle and you don’t know where to turn, I would go online:
- Look up the local Chamber of Commerce.
- Look up your local government.
Montgomery County has so many resources available, and some of them are free. Some of them are low-cost, and some of them are based on your income.
So don’t let that sort of stuff stop you from investigating and looking out seeking help.
There are many mental health resources in our area and many places, not just this area.
But don’t sit at home and struggle when somebody might be out there who can help you.
Ryan Miner 14:21
I’m glad you brought that up – because the goal of our Senior Soup media and advocacy organization is to aggregate all of these resources into one place to help people quickly find them in the DMV area, especially our aging population.
Our thought pattern was how can we get people information as quickly as possible, where they don’t have to go out and search and search and search, and on top of that, they can hear from experts like yourself.
Margie, you’ve been here for 30 years or more.
Raquel Micit 14:50
Can you add applause here?
Ryan Miner 14:42
Yeah, exactly!
Margie Hackett 14:54
Yeah, It’s been a long time.
Suburban Hospital Customer Service
Raquel Micit 14:55
I do want to give Suburban Hospital a lot of kudos here.
We talk about how you guys make us feel in this hospital. It’s like that saying, ‘People won’t remember what you did exactly, but they will remember how you make them feel.’
When you walk into Suburban Hospital, Freddy is at the front.
Oh, my gosh!
Ryan Miner 15:12
I’ll tell you right now; I have never walked into a hospital where someone makes you feel so welcome.
The customer service is on point.
Ryan Miner 15:19
How can the community at large financially support hospitals?
It takes a lot of money.
We want to know how to support you and your team here at Suburban.
Margie Hackett 15:28
We get money from insurance companies, right, and we get money from the state.
The special extra programs that are not necessarily built into the budget would be something that would help all hospitals.
We all want to do special projects, you know?
The agencies that want to help the patients in the community, the residents in the community, because you’re not a patient in the community, you’re a person, you’re a resident, and how do we help those people are getting more education to them or more initiatives to help them when they need it.
For example, every hospital has a foundation.
They’re all collecting money, which goes towards special projects or special education for their staffing.
We have a fund that helps pay for the education of the nursing department. So when a nurse wants to go to a conference, we have money that pays for that.
We have money that we use for special programs.
We have an initiative with a couple of private duty home health agencies. We’re constantly brainstorming. You guys are brainstorming as well. You know, how can you help the hospitals?
What can we do to work together to help this population? There’s a gap; we’ve identified a gap.
How can we help them?
It’s usually not going to come from hospital funds. It’s not going to come from the insurance companies. It will come from private citizens who donate to the hospital.
So Suburban has that department.
And the other hospitals as well have a fundraising department.
Ryan Miner 16:30
Pull out the checkbook!
Write a check!
It doesn’t have to be for a lot. It’s however much you can afford at this time and support your local hospital system – because they are constantly keeping us – 24/7, 365.
When we think of the word community, the hospital is at the center of it.
National Case Management Week
Ryan Miner 16:49
Hey, Raquel, it’s a special week.
Raquel Micit 16:51
It is!
Happy National Case Management Week!
Margie Hackett 16:56
Thank you!
Ryan Miner 16:56
We got you a million dollars.
Margie Hackett 16:58
Oh, that’s exciting. I’ll give it back to the hospital foundation.
Ryan Miner 17:01
Well, you should probably keep it. I think Suburban, after your tenure here, they would be okay.
Margie Hackett 17:06
Do you think so?
Raquel Micit 17:07
What happened to the golden tickets, you know, in the chocolate bar?
Ryan Miner 17:10
The giant checks…
Margie Hackett 17:11
I would like those.
Preparing Yourself For A Hospital Stay
Margie Hackett 17:12
Okay, one more thing I want to add to something I said earlier:
What can we do to help people prepare?
I mentioned that people don’t expect to come to the hospital; you’re never prepared.
If you might need a skilled nursing facility, visit some nursing facilities.
Get to know them; be comfortable around them. Don’t be scared walking in. They’re lovely, happy places to be.
And if you don’t have a good vibe about one, go to another one.
But go in and meet the people, and have lunch there. They want to show you what they can do for residents, which is awesome.
Also, get to know home health agencies.
Go out to some of these health fairs.
Find out different resources available for you.
The home health agencies want to talk. They’re there to help you as well.
So get out there, and don’t stay in a little hole. Get out there, find out what’s around your area, and then you’ll be ready.
Margie Hackett’s Advice For Your
Raquel Micit 17:53
So, Margie, we’ve covered so many great things.
If we were to give our audience three key takeaways, what would you want them to take away from this podcast?
Have a Relationship With Your Primary Care Doctor
Margie Hackett 18:03
- See them regularly.
- Take the recommendations.
- If you’re struggling with the recommendations, talk to them about it.
- Get some advice because you know their goal is to make you happy and healthy.
- So don’t avoid them.
If you feel bad and have some struggles in between, before your next visit – he says you don’t have to come back for a year, but you have trouble at month four – don’t wait that six months; don’t even wait two weeks.
Call your doctor.
Trust Hospital Case Managers
Trust the case management team.
Be An Advocate For Yourself
- Stand up for yourself.
- Ask questions.
Trust they will try to put the best plan in place for you based on your situation.
Keep asking questions so you can understand them.
Ryan Miner 18:39
Open your checkbooks!
Raquel Micit 18:40
Open your checkbooks!
Ryan Miner 18:41
Open your checkbooks and consider a donation that will go to the hospital foundation.
They will, in turn, push an initiative out and support our community.
Raquel Micit 18:51
Well, thank you so much, Margie.
I love that we touched on how to prepare ahead of time, educate ourselves, feel empowered, make these decisions, and continue to thrive as we age – gracefully.
On that note, I think that’s a wrap.
Right, Ryan?
Ryan Miner 19:10
We had fun today!
This was great!
We have to lighten it up a bit because talking about hospitals is not always the most enticing subject.
You made it fun, Margie; you’re always a blast.
We love seeing you out!
And you came to our Senior Soup launch party, and we have a little gift for you.
Raquel Micit 19:26
We sure do.
Margie Hackett 19:26
Isn’t it that million-dollar check you mentioned earlier?
Raquel Micit 19:27
Of course!
Ryan Miner 19:27
Yes, that’s right!
Ryan Miner 19:30
Thank you so much again!
Raquel Micit 19:31
If you get Margie, you get to work with her at Suburban Hospital; smile.
Say ‘Hi.’
She’s the best
Ryan Miner 19:37
She is the best!
Margie Hackett 19:37
Thank you!
Ryan Miner 19:38
That’s it for today.
Raquel Micit 19:39
Have a great day!
Margie Hackett 19:40
And thanks for having me on, you guys!
