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Discharge planning starts on day one

From a patient's very first day in the hospital, case manager navigators are already considering what that patient will need after their stay.

¡°Discharge planning always starts on the day of admission,¡± Wilson says.

You¡¯ll typically meet with your case manager navigator for the first time shortly after you are admitted at MD Anderson.

At this meeting, a case manager navigator will ask questions about your background, living situation and care needs. This assessment enables your case manager navigator to connect you with resources or educational materials that you may need.

¡°We help patients through that process to make sure their questions have been answered and that they feel comfortable going home by the time they're medically ready for discharge,¡± Wilson says.

Ensuring a seamless transition from hospital to home

Each patient has unique needs, so case management services look different for each patient. But while needs vary, the goal of case management is the same: to bridge gaps between patients, families, MD Anderson and other care providers to ensure high-quality care coordination.

Here are some of the services a case manager navigator may provide.

• Discharge planning
• Arranging air and ground ambulance transportation
• Helping you get the medical equipment you need for home
• Coordinating services such as infusion therapy
• Connecting you with home health providers that can help with skilled services
• Post-discharge coordination with skilled nursing facilities, inpatient rehab hospitals, long-term acute care and hospice services, if appropriate

Case manager navigators at MD Anderson also work closely with other teams and services. For example, your case manager navigator may connect you with:

• Social Work: These professionals can help you navigate non-medical issues such as lodging and transportation, provide patient education and support your emotional care needs.
• Financial Clearance Center: This team can answer questions related to insurance and benefits.

Case manager navigators as patient advocates

While case manager navigators juggle plenty of logistics, they also serve as patient advocates. But, to provide options that help patients meet their care needs, case managers first need to identify what those needs are. That's why Wilson encourages patients to speak up about any concerns they have regarding their care at MD Anderson or their transition to care at other institutions post-discharge.

¡°We are advocates for patients as well. We really do want to encourage patients to have candid discussions so that we can help them work through challenges,¡± she says.

For Wilson, this blend of business, health care and helping others is what makes her role so rewarding.

¡°I love helping patients, and I think that's why most of the case manager navigators are in the position that they're in. It's the perfect role that has a combination of understanding the business side of health care but also interacting with patients. Learning how to help navigate that and being able to help a patient is one of the things that we really, truly cherish,¡± she says.

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