Paving the road to recovery: Care Management team helping COVID-19 patients find success
For the past two months, teams across Michigan Medicine have been working toward one goal — caring for patients with COVID-19 and slowing the spread of the virus. But for one team, the focus is not on the direct medical care patients are receiving. Instead, it’s on ensuring that individuals have the resources and support they need to make a successful recovery.
“As a team, our mission is to improve the health outcomes of patients by coordinating with them, their families and health care team members to optimize access to the right level of care at the right time and place, and at the right cost.,” said Renee Bremer, M.S.N., R.N., A.C.M., associate director of Care Management Nursing Services. “COVID-19 has presented new dynamics to problem solve for safe patient discharge, many of which our teams are uniquely skilled to address.”
While many Care Management nurses and social workers are helping with patients recovering from COVID-19, three staff members are specifically working in the Regional Infectious Containment Unit, or RICU.
“When the opening of the RICU was first announced, I volunteered right away,” said Brian Nickerson, LMSW, a social worker in Care Management. “I have experience working with pulmonary patients, which I thought would be useful because COVID-19 seemed to have a significant impact on respiratory health.”
Nickerson now admits that nothing could have prepared him for what he was about to experience.
Nickerson is part of a team of social workers and nurses from Care Management who have partnered closely with local public health departments, Infection Prevention and Epidemiology (IPE), and provider and nursing teams at Michigan Medicine to create and implement best practices in the care of patients hospitalized with COVID-19.
“One of the hardest parts of caring for this patient population is the feelings of guilt and isolation that come with being infected,” said Nickerson. “Many patients are scared that they may have put their families at risk, worried about their family members at home, and feeling incredibly isolated because friends and family are unable to come visit them.”
In the RICU specifically, many patients are on ventilators and therefore are unable to communicate with their care teams. Nickerson and his colleagues, Emily Fagre, LMSW, and Caitlyn Sultana, LMSW, step in on their behalf, reaching out to family members to identify who will make health care decisions for the patient and establishing a relationship with them.
“It is more important than ever for us to make connections with our patients’ family members because they are unable to be here in person,” said Nickerson. “We identify who will speak on behalf of our patient and often speak with them several times throughout the day to keep them updated on the loved one’s progress.”
Helping patients recover
More than 400 patients have been discharged after receiving treatment for COVID-19 at Michigan Medicine and these patients face unique challenges as they return home. Dan Alverson, R.N., BSN, C.M. is one of the case managers who works with patients after they have been moved from the RICU to a step-down unit.
“Once patients reach my unit, they have typically been in the hospital for two weeks or more,” said Alverson. “Their bodies have been reduced to almost nothing after spending nearly the entire time flat on their back on a ventilator, literally fighting for their life. We help them gain enough strength and stability to be able to leave the hospital and continue their recovery, usually in a long term acute care, skilled nursing facility, or at home with Home Health Care.”
After spending weeks on a ventilator, the patients’ fight with COVID-19 is far from over. Alverson and other nurse case managers help patients plan for the next phase of their recovery.
“We coordinate with our patients, their family members, our care teams and insurance providers to help patients understand their options and make sure they can continue their recovery in a setting that is more beneficial for them,” said Alverson.
Preparing for discharge
Both social workers and nurses in Care Management work with patients and their families as they prepare to discharge from Michigan Medicine.
“As patients prepare to leave the hospital, our teams help them answer many important questions before leaving,” said Nickerson. “They need to consider many factors including, how will they pick up their medications? Do they have food in their house? Can they go to the grocery store if they are contagious? If their family is also ill or they do not have family, how do they get home from the hospital?”
Care Management social workers begin planning for the answers to these questions with patients and families at the beginning of admission. They also connect with patients the day before or day of discharge to ensure that they and their families have been able to find solutions to these questions and offer assistance with any outstanding questions.
“Pre-COVID, I often knew exactly what path patients would take, but this virus has presented all of us with new challenges because each individual patient’s care pathway looks very different,” said Alverson. “This virus is causing any pre-existing conditions that patients may have to flare up, creating even more health issues. Even as patients recover, they often take two steps forward only to take three steps back the next day. These daily changes make it difficult to plan for the patients’ next steps so it is even more important for me to coordinate their health care on their behalf.”
During the pandemic, the team also works to support some of the most vulnerable patients, specifically those that are homeless or who do not have the support necessary to successfully quarantine and provide for themselves at home post-hospitalization.
For these patients, Care Management teams have partnered with local public health departments across many counties as well as community service organizations and medical transportation providers to help patients obtain groceries, discharge transportation, medications and housing.
“COVID-19 has presented new psychosocial needs for patients, many of which our teams are uniquely skilled to address. Our homeless population is one of our society’s most vulnerable and will likely experience a lot of hardship as they recover,” said Gariann Brock, LMSW, ACSW, C-ASWCM, associate director of Care Management Social Work Services. “That’s why we’re working so hard to protect them – and everyone who is fighting to recover from this disease. It’s what we do.”