By Jody Luttrell MSN, RN, CCM

A call comes into my office from the local trauma center case manager; she wants to refer a 16-year-old boy who was injured in a car crash last Saturday night. He came in with a severe head injury, pelvic fracture, and several lacerations. He is still intubated, but he will get a tracheostomy and gastrostomy tomorrow. Can he be admitted for rehabilitation? The next call is from his mom; she wants to share that he is the quarterback on the football team, wants to play in college, has a girlfriend, and gets straight A’s. Can we help him?

My mind immediately goes through a series of scenarios that the family has yet to even imagine. Here is a shout-out to a cohort of case managers who also have in their job descriptions such duties as “referral liaisons” or “rehabilitation admission coordinators.” In my experience, this case management role serves a part in the coordination of a transition of care along a rehabilitation continuum.

At our pediatric rehabilitation hospital, the nurse case manager also follows the patient and family from admission through discharge to home or longer-term facility. It is a complex task to manage successful transitions along this continuum and to do this multiple times a day or week. This professional case manager role collaborates with the acute care case manager, meets, and helps guide a family in the middle of their personal nightmare. This unexpected injury has happened to a loved one and the family is thrust into the strange world of an ICU, not even sure of life and death.

Finally, the family gets the word of their person’s expected survival. Then, they get the word that the next step is rehabilitation which could be an acute rehabilitation setting, LTACH or SNF:  all foreign words to the family. The family and friends will frequently be searching the internet for information and turning to the ICU or rehabilitation case manager for guidance. It is a privilege to be able to understand what the potential long-term outcome for this patient may be and to help the family begin to set some expectations for next steps.

In this role, all the components of the case management process are used as an important part in the transition of care for the patient. The liaison case manager will do an onsite or virtual review of medical records and confer with the Rehabilitation Medical Director as well as Director of Nursing, finance office, and possibly other resources: such as respiratory therapy, nutrition, therapies, and social work. Having a good knowledge of diagnoses, other rehab and support services, and insurance coverages are vital to success in this role. Seeing this young person now with a severe injury and knowing his future goals have changed is mentally challenging as a nurse.

I take strength in knowing that he will receive excellent care and remain hopeful for a good outcome. Pre-admission questions to ask include: is this person medically ready for rehab? Are they a good fit for our program? What is the insurance coverage? Do we have a bed? What is the potential discharge plan? (Discharge planning starts now!) All this discussion needs to take place quickly as post-acute settings operate in a competitive market, and the referrer is also under pressure to open the acute bed. Through my years in this role, I have talked with many case managers that have this job. I have found that we share some common traits and stressors.

Those who are successful and enjoy the job like meeting people and can make quick personal connections, have great assessment and critical thinking skills, and enjoy a new challenge daily. Common stressors are due to the multiple stakeholders involved with each referral. It is often just as difficult to decline a patient and to share that news and reasoning with the referrer and family as it is to accept a patient and to share that news with your inpatient team and to coordinate on many levels for a successful admission.

Case managers in this role are hopefully looking calm, but it is important to recognize the challenges and stressors. I find it helpful to check in on the patients you have admitted so that you have a sense of closure, and you can also share outcomes with the referring case manager. Staying in touch with your inpatient team and feeling a part of the team will help with collaboration for admissions. Talking (and laughing) with others in similar roles and sharing common ideas is also helpful. If this is your role as a case manager, you may not get a lot of actual thanks from a patient, family or even your own team, but please know you are a vital part in the transition of care and very much appreciated!

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Bio: Jody Luttrell is the Director of Care Management at the Kennedy Krieger Institute in Baltimore, Maryland. She currently serves on the National Board of Directors of CMSA as well as her local chapter, CMSA of the Chesapeake. She has presented at the local and national level on a variety of case management topics.