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case management, medication reconciliation, transitions in care



  1. Stanton, Marietta PhD, RN-C, CNAA, BC, CMAC, CCM
  2. Dunkin, Jeri PhD, RN, CHCE


Purpose/objectives: Case management activities were reviewed in a rural, nurse-managed, primary healthcare setting over 3 months. The purpose was to determine the specific case management tasks and how these functions related to, or enhanced, lateral transitions in care. The transition from outpatient to inpatient care implies a vertical transition of care, as the care at the hospital level is more complex than in a physician's office. Many times, patients will move between different providers and clinics in the outpatient (or inpatient) setting; these are considered lateral transitions. In a nurse-managed clinic, there are many referrals, hence many handoffs. As these patients move to and from these appointments and referrals, new tests are conducted and new medication may be ordered. To maintain a high quality of care, new therapies and medications must be integrated into the plan of care.


Primary practice setting(s): This study was conducted in a rural, nurse-managed, primary healthcare setting; however, the results are generalizable across many settings.


Findings/conclusions: In this study, it was determined that the case managers were managing the transitions between the clinic and other outpatient services, as well as managing and ordering the patient's medications and therapies. Approximately 45%-50% of case management functions involved either obtaining medication assistance for patients without funding or assisting patients with the ordering and procurement of essential medicines. Another 45% of the case manager's time was spent coordinating referrals to a wide variety of specialty clinics for diagnostic testing, obtaining appointments with community-based family practice physicians, or coordinating examinations for specialty physicians.


Implications for case management practice: Transitions in care have become a major focus in promoting patient safety. Case managers at the primary, secondary, and tertiary levels of care play a major role in making these transitions safe, whether these transitions are vertical or lateral. Safety issues come into play as patients move back and forth-or up and down-in the system, because providers do not always manage the safe handoff of the patient to other outpatient or inpatient services.