Care management & social work

Preparing for discharge

Soon after admission, you’ll meet your care manager and social worker to discuss how long your anticipated hospital stay and services you may require for post-hospital care. The care manager and social worker on your unit will offer information, assistance and guidance to you and your family. They will also advise you about our discharge procedures when it’s time for you to leave the hospital.

Care management & social work

Care managers are an integral part of a patient’s health care team. They help safely move patients through their phases of care from admission to discharge, in coordination with the clinical team and patient. Care managers will make appropriate referrals to rehabilitation facilities and nursing homes along with referrals to home health care providers for assistance with home care or with procuring medical equipment for patients who are returning home after discharge.

A care manager will:

• Ensure that all plans for a patient’s discharge are covered by their insurance, or discuss private pay when needed • Assist with setting up transportation when appropriate • Work in conjunction with the social worker to place a patient and when any disposition issues arise • Set up necessary appointments if the patients’ condition requires immediate physician attention following discharge • Make sure that home care agencies order the necessary equipment for the home from a durable medical equipment company • Provide utilization reviews to the insurance companies • Provide education to patients and act as a liaison to their physicians

What does a social worker do?

Social workers are valuable resources for patients and their families. They provide social, emotional and medical support as patients transition from the hospital to their next care setting. If skilled nursing or rehabilitation services are required, social workers will assist with placement. They will also make sure patients have all of the resources they need to safely and successfully return home. Our social workers focus on finding the optimal post-discharge destination and services for each patient.

A social worker will:

• Make suggestions and provide lists of support groups, drug and alcohol treatment facilities, psychiatric care, shelters, hospice centers, etc. • Connect patients to the appropriate provider of choice, including in-network Catholic Health facilities, for continuing health care after leaving the hospital • Support patients as they transition from admission to discharge and post-hospital care