Care Management: Many Moving parts, One Team

April 30, 2020  //  FOUND IN: Accolades and Milestones

The mission of Care Management is to improve health outcomes by coordinating with patients, families and healthcare team members to optimize access to the right level of care at the right time and place, and at the right cost.

Transitions of care are often challenging. The challenge has been heightened over the past month in the midst of COVID hospitalizations, treatment and readiness for discharge. Case Managers, both RN and SW, have been serving our COVID and non-COVID patients by removing barriers to discharge, and bridging gaps between clinical staff, caregivers, patients, and our community partners.

Removing Discharge Barriers

There are many medical unknowns related to COVID, such as how long are patients contagious, how long are symptoms going to last, when do symptoms peak, what is the best treatment, how to manage our Covid positive family members at home. Despite the unknown Care Managers have been able to support transitioning even our most complex patients. During non-pandemic operations, typically 35% of admitted patients require assistance from a Care Management related to discharge needs. Patients who are COVID positive present with increased complexity of needs requiring skilled care, psycho social support, or complex care management to ensure safe discharge and the ability to adhere to quarantine protocols while meeting their basic needs. !00% of Covid positive patients require a Case Manager to assist them to the next level of care.

Care Management screens 100% of admitted patients to ensure they will have a safe transition to their next level of care. For those that need services such as home care, sub-acute rehab, hospice, DME, psycho-social assistance, and more; our RNs and SWs work together to remove discharge barriers.

CMS has put many waivers in place in order to help with transitioning patients during the COVID pandemic, such as:

  • Eliminating the required 3-day inpatient stay for sub-acute rehab
  • Facilitating DME orders so they now be obtained as needed (there is a rule that it can only be ordered every 5 years)
  • Eliminating the required prior authorization for Home Care.

The RN Case Managers work hard to ensure we are always in compliance, doing what is best for patients, and educating our residents on transitions of care. During the COVID pandemic we have continued to work closely with our post-acute care providers, to facilitate discharges. While continuing to arrange post-acute services for our non-COVID patients, we have also rose to the COVID pandemic challenges. To date we have discharged 379 COVID patients, 40 to sub-acute rehab, 4 to the Detroit Field Hospital, and the rest home.

There is a whole team of RN’s in care management that do Utilization Review. These nurses work with our providers to ensure the patient in the right level of care (outpatient, inpatient, observation or extended recovery.) They work with our insurers and CMS to make sure that every stay and every day of the patient stay is medically necessary AND paid for. Wow what a challenge in the COVID crisis! COvid-19 is a new diagnosis and new virus that comes with a myriad of symptoms and complications. Hats off to our UR nurses for sorting all this out and helping us get reimbursed for the excellent care we deliver to our patients


Social Work Case Managers continue and augment the work of the RN Case Managers through facilitating hospice discharges, as well as mitigating psychosocial barriers of quarantine including access to prescriptions, food, stable housing, and social supports. Social Workers collaborate closely with Public Health across the state of Michigan. They also provide crucial end of life support and guidance for families experiencing a loss related to COVID-19. Care Management Social Work has intervened on 91% of patients admitted with COVID-19 at Michigan Medicine.

Being a Conduit for our Caregivers and Patients

During the COVID crisis our team had many volunteers to work the RICU. As the RICU, was the first location to consistently care for COVID Patients, the Care Management Staff that volunteered for this assignment were integral in creating the best practice workflows and guidelines for the care of patients positive for COVID-19. Their innovation laid the ground work for what has become exceedingly smooth and proactive patient care during the COVID-19 Pandemic. The team work has been amazing with many Surgical Case Managers volunteering to take COVID patients during this time of working differently. Our SW Case Managers have been valuable in connecting families and patients especially in the RICU. They are utilizing technology to communicate with loved ones for patients throughout their hospitalizations. Social Workers also respond to all Codes throughout the hospital to provide crisis intervention, updates, and partner with the medical team.

A few good stories:

  • A young female patient required a life vest, but was allergic to the metal, the RN CM worked endlessly to get a gold vest here for trial. Patient was successfully discharged and did not readmit. (would need to get more details from Rachel W before we submit)
  • Patients travel here from all over the country and worldwide to receive our services.
    • We were able to work with the consulate to transfer a patient back to Japan for end of life care with his family.
    • A patient visiting from UTAH needed sub-acute rehab and desperately wanted to go home, we successfully transferred her there and ensure everything was covered by her insurance including transportation.

A husband and wife who were both admitted to the RICU and had to be intubated within a few days of each other. For almost a full month they were both intubated/sedated. SW provided daily support to their only son. Both patients were moved into the same room, and it was a long, scary three weeks for them and their son. Both patients were eventually successfully extubated within a day of one another. RICU staff started pushing their beds together so they could both FaceTime with their son every day. When they were both transitioned to new units in UH, the RICU staff lined the halls of the RICU to applaud them as they left. It was so validating for RICU staff to see the story of this couple end happily.


When you ask Care Management staff for good stories you will have a hard time getting just one. The culture of excellence is high as that it the standard practice. This is the work we do every day and we all work together with every member of the multi-disciplinary team in order to ensure the best and safest transition of care for our patients.