Case Manager Playbook (Assistant Coach)

You are the team’s Assistant Coach and Team manager. You are the team’s primary link with the administration and our health care systems.
Whenever possible you should be assigned to a specific physician or physicians for several weeks. This arrangement encourages effective and efficient communication because you become familiar with the physician’s communicates style and the physician develops a progressively better understanding of how you communicate. Your discussions should be collaborative.

• 9:00-9:15 AM every weekday you meet with the hospitalist and charge nurse at the nursing station to review each patient’s equipment and nursing needs outside of the hospital. 
• 9:15-11:00 When possible attend bedside rounds particularly for patients who will have complex discharge needs. Huddling with the patient, patient’s family, bedside nurse and physician assures a more robust and customized plan that reduces the likelihood of readmission.
• 3:00-3:15 PM – Review the needs of patients who will be discharged the following morning.  
• Understand the needs of the patients and their families. Discuss with the physician equipment and home nursing needs if planning a home discharge. 
• Assist in placement of patients in nursing homes and rehabilitation facilities
• Assist with other discharge planning issues and assure that the proper documentation accompanies the discharged patient facilitating an efficient and accurate handoff. On the day of discharge you are responsible for coordinating all the components of the discharge (you are flight coordinator)
• Provide data on the percentage of patients discharged before 10 AM. You will be evaluated 

Suggestions:

• Succinct and efficient presentations: You need to speak confidently and efficiently.  Quickly summarize disposition issues and make suggestions for improving the quality of care so that these specific changes in management can be ordered during rounds. Remember efficient communication is a key fundamental.
• Active involvement. You will be encouraged to participate. If you contribute to and understand the management plans, care will be more efficient and less error prone. This will allow more effective discharge planning.
• Horizontal communication: Unlike traditional models, this is not a top-down structure. Each person has unique roles and makes unique contributions. It is important that everyone feel empowered to contribute during rounds. It is critical that you actively participate. It is important for you to contribute your ideas in order to learn and also in order to provide your patients with the best care.
• Teamwork: To assure timely and efficient discharge plans continual communication and effective teamwork are critical. The case manager should work closely with the bedside nurse, hospitalist and pharmacist to complete all discharge forms and discharge instructions and with the help of the discharge coordinator assure that each patient is properly handed off to a primary care physician. The case manager’s primary responsibility is to assure that each patient has the appropriate support systems and contingency plans in place, otherwise the probability of readmission is greatly increased. We all sink or swim as a team.