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.
Inpatient case management
Case 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.
Admission and continued-stay review
We review hospital, skilled nursing facility, 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 preauthorization 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.
Out-patient case management
Our nurses provide case management services across multiple levels of need for members who may need that extra level of guidance whether it is maneuvering through the twists and turns of health insurance processes or education for a medical condition. Our case managers are skilled at assisting members as they transition back into the community as well. By following those members that are medically fragile after an inpatient admission we are better able to ensure our members receive the right care at the right time at the right setting. By ensuring our members are getting the right care at the right time at the right site of care our nurses can better manage utilization of services and reduce unnecessary cost.
Emergency Patient Resource and Options Program (EPRO)
Our EPRO department provides 24/7/365 oversight and guidance for our patients visiting an emergency department. Emergency department providers can have a real time discussion with our EPRO physicians providing clinical and service utilization guidance as needed. Our EPRO team also focuses on repatriating our members seen in non-rounded or non-contracted emergency departments back to our preferred network supporting Kaiser Permanente’s focus on continuity of care.
Emergency Patient Resource and Options Program: