Care management nurses

Our care management nurses and hospitalists monitor a member's inpatient care. Care management nurses are available by phone to assist patients and clinical teams in outpatient settings.

Their responsibilities include:

  • Ensuring that the member's physician is aware of or involved in the case.
  • Facilitating the flow of information between the hospital and Kaiser Permanente.
  • Assisting hospital discharge planners.
  • Confirming coverage through Review Services or Member Services.
  • Facilitating the use of Kaiser Permanente or contracted providers.
  • Answering member questions about coordination of care.
  • Facilitating high-quality, cost-effective use of medically appropriate resources.
  • Initiating and participating in patient-care conferences and utilization review committees.
  • Educating internal and external staff about case management and care coordination.
  • Orienting new contracted providers to Kaiser Permanente.

Coordination of care

Care management nurses review admission reports and coordinate with hospital social workers and discharge-planning staff to ensure early identification of high-risk patients and timely discharge planning. After discharge from acute care facilities, our nurses continue to coordinate care. Our nurses also call the patients approximately 48 hours after discharge to ensure that their transition to home is going well and that follow-up appointments have been made. If a patient is having difficulty, the care management nurse will facilitate a same-day appointment to avoid readmission to the hospital.

Case management

Our nurses serve as case managers for members whose needs are complex or when resource allocation decisions are required. Case management may cross many settings throughout an episode of illness or treatment. Case management nurses can follow a medically fragile patient after discharge to ensure smooth transition to the next level of care. They are also able to work with patients in advanced stages of chronic illness to understand how to cope with their disease and provide symptom management.

Interhospital transfers

EPRO physicians can help with interhospital transfers 24/7/365. They can help get bed availability, accepting physician, and facilitate transportation.

Emergency Patient Resource and Options Program:
Toll-free: 1-800-337-3197

Admission and continued-stay review

We review hospital, skilled nursing facility, nursing home, and home health admissions for clinical need and appropriateness and to identify coordination of care needs. Continued stay reviews focus on high-risk diagnoses, variance from length of stay guidelines, and coordination of care needs. Many of our plans require pre-authorization for planned admissions.

Our care management nurses work closely with a facility's utilization review staff to conduct reviews and coordinate care. If the admission or continued stay appears to be inappropriate, our nurses, in conjunction with the patient and the multidisciplinary team, develop an alternative plan. Our nurses may request a second-level physician review to determine the reason for decertification.