Care Managers: The masterful navigators guiding hospital journeys

October 31, 2023

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Imagine that your mother had a stroke. After three days in the hospital, she’s stable and now scheduled to be moved to an assisted living facility under hospice care. Not everyone has been consulted but the doctor, facility and hospice are tentatively thinking along the same lines: She is ready to be moved.

However, she isn’t. Critical details about your mother’s needs at the facility haven’t been confirmed or clarified. Is there a proper hospital bed, for example? Have hospice representatives visited the facility to ensure compatibility?

What should you do if you are overseeing your mother’s care?

Enter care managers, enormously critical hospital personnel who operate under the radar but affect every patient that enters a hospital. To patients and families, they seem merely to be the administrators who finalize paperwork before patients are discharged from the hospital, thus freeing up hospital beds for other incoming patients.

But the truth is more complex. Sure, care managers facilitate patient discharges. More importantly, they ensure that patients are going to the right place and under the right circumstances.

“Yes, we work to discharge patients into the community so beds open up in the hospital for other patients who need them,” says Ashli Beavers, the care management manager at Legacy Emanuel Medical Center. “But the deeper reality is that we oversee how a patient might be placed or discharged from the hospital and determine where they go to next and what it is they need. You make that assessment with physicians and all the other ancillary services.”

In the hypothetical scenario, for example, getting the attention of a care manager would clarify whether all protocols and checks have been taken before your mother is moved.

Beavers says that making decisions as a care manager is more art than science, more about experience and intuition than dutifully following protocol and rules. The job relies heavily on qualities common to an investigator: asking questions, sniffing out problems and finding resolution while artfully dealing with nearly every kind of hospital personnel and ancillary service. This would include nurses and physicians and service lines such as rehabilitation and assisted living facilities, hospice care and more. This intangible quality is helpful because situations are often unclear.

Sometimes, patients are medically stable and ready to discharge from the hospital without a hitch. But sometimes they go home and require home health services. Or sometimes they go home but with caregiver service needs. Still other times, a patient may be houseless and has to be housed in a particular kind of facility. It’s up to the care manager to find the right match financially and otherwise.

“We often have to get very creative in order to pull in all of the resources to get patients what they need,” says Beavers. “We’re the problem solvers at a hospital.”

Care managers must have a clinical background, in nursing or social work. But there is no singular path to become a care manager. What’s true is that the role has evolved in recent years because of the growing complexity regarding patient needs as well as the health care industry itself.

“Historically, I think that discharge plans were heavily driven by the provider team and by the therapy team,” says Beavers. “That has changed as the sophistication and complexity of the health care system has changed.”

Beavers has been a nurse for 14 years. She first started in health care as a caregiver then moved into a job as a certified nursing assistant before becoming a nurse in the post-acute and long-term care sectors. In the hospital setting, Beavers previously worked as an inpatient nurse, nurse case manager and also in population health.

Beavers says the hierarchy of the job, its structure and the level of responsibility and autonomy it demands makes it different from, say, bedside nursing. That’s one of its appeals.

“This is a great moment for innovation in care management and hospital care management,” she says. “We need people from all kinds of backgrounds, of all ages, cultures and genders who really want to be in a position to make a big difference in a patient's life as well as in the hospital.”

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