Whether it is getting advice on how to schedule follow-up appointments, arranging transportation or if patients need to receive continuing support after they leave our hospitals; the PARC is here to help. The needs of our patients have increased over the last few years. “When we noticed that we were having an increase in people that needed services after discharge, we also found that there were all these other challenges that were increasing in order to get them what they needed,” says Nita Dunham, Senior Director for Case Management.
The complicated part for Monument Health has been that many of these services were being handled by different people in different departments, all across the organization.
So, the Case Management team at Rapid City Hospital, partnered with Christy Gerdes, Project Manager and Mandy Martinez, EPIC Analyst to lead an innovative project to bring Case Management services together in one place — both physically and philosophically. The effort, Nita felt, would streamline all of the different moving parts and create a more efficient, Monument Health-wide system to evaluate and meet patient needs, post-discharge.
Thereafter ensued an 18-month project to make what is now called the Post-Acute Referral Center (PARC) a reality. The idea is for individual Case Manager Assistants, each with a different specialty background, to be the sole point of post-discharge coordination and for the Social Work / Registered Nurse Case Managers to focus on the progression of care for our patients with the clinical team in the care areas.
A major concern was integrating the Epic system so that the various parties involved could communicate with each other. Another more major hurdle to clear, though, was simply buy-in from Caregivers who were accustomed to performing Case Management actions by themselves or under the older, more complicated methods to which they had grown accustomed.
With this in mind, the PARC project team knew that they would need a lot of input from different disciplines on how such a centralized case management system could be implemented. So they devised a World Café exercise, which functioned as a think tank for the various departments to come together and brainstorm about how this new PARC would function. Implementing the results of the collaborative exercise, the PARC project team fleshed out a long term plan. “September 2023 is when we started relocating individuals to the PARC office, and then we went live in March of 2024,” says Hailey Twietmeyer, Social Services Manager.
“We have some of our patients come to us from communities that are hours from here, and so trying to figure out what services are available in those communities, the Case Manager Assistants have the dedicated time to research that stuff. And so it really has helped a lot by centralizing that,” says Nita. “The case managers assistants put it all together with the provider and the patient to say, ‘What are the patient’s goals? What do they need? What do they like to see happen?’ And then they package it all up for when the patients are ready to leave the hospital setting.”
The Case Manager Assistant’s involvement allows RN/SW Case Managers to focus more of their efforts on progression of care. The goal is not only to discharge patients faster, but also to cut down on preventable recurring visits that happen because of oversight or of inadequate communication. Because the average length of hospital stays will likely decrease, the PARC project should also pay dividends on the overall bottom line, as well, according to Christy.
PARC continues to refine processes based on Caregiver feedback, but the response so far has been enthusiastic. “We recently presented at the annual South Dakota Association of Healthcare Organizations, and I’ve already gotten numerous phone calls from people saying, ‘How the heck did you do that?’ And then we’ve also been asked to publish an article about it in the American Case Management Association Journal for the spring issue. ” says Nita.
Quality Assurance also took notice and honored the project with their most recent Quality Showcase Award, which is an added affirmation that the PARC project is making a difference.
Looking ahead, the team will research bringing the same model to outpatient care and figure out how to work through hurdles — such as implementing Epic — to expand and grow, so that Caregivers are best suited to support patients throughout our system.
Story: Kory Lanphear