We can help you and your family address any concerns about a current illness or hospitalization, and anticipate future care needs. If you have complex care requirements, the medical team will order a care coordination consult to assist with later referrals.
After leaving the hospital, your transition needs may include nursing facilities, acute rehabilitation, coordination with your primary care provider and community resource referrals.
To speak to one of our care management team members, just ask your nurse or physician.
Working together to improve your care
To achieve better results, our interdisciplinary team promotes more communication between physicians and insurance companies.
We focus on the early identification of patient needs and the daily evaluation of patient progress toward specific goals.
In addition, we develop a comprehensive discharge plan to address the need for placement in a facility or palliative care services, and any behavioral health needs.
Care management teams include the following roles:
- Assess and help patients and families with complex discharge situations to navigate their options for placement and community assistance.
- Assess and help patients with long-term issues such as chronic pain, homelessness and substance abuse, through community-based care.
- Provide crisis intervention when patients and families experience trauma, death or a crisis situation.
- Assess patients on admission for medical complexity.
- Collaborate with the care management team on discharge planning needs.
- Monitor clinical processes, quality and efficiency.
- Address the needs of patients with complex psychosocial needs.
- Help or refer patients who need outside resources or community assistance.
- Help or refer patients regarding medical and legal issues as well as counseling.
Care management assistant
- Act as a resource and advocate for patients and families in negotiating the healthcare reimbursement system.
- Conduct initial and concurrent review of medical necessity as well as a review for appropriate admission status.
- Comply with all Medicare regulations as they relate to clinical conditions and payment.
- Provide clinical information to third-party payers to assist in payment of their claims.
Outpatient care manager
- Work with the telemedicine program that monitors the patient from home using wireless, real-time technology.
- Coordinate with physicians about a patient's daily medical progress based on weight, blood pressure, food intake, medications and more.