Patient Care Coordination Most people probably have no idea what it takes to fully coordinate a patient’s care. When a patient is hospitalized there is an examination of what their needs will be. If they will be hospitalized long term, there must be coordination over insurance and finances. Do they have insurance that will cover everything, or will they need a form of state Medicaid? If they need state assistance, the social worker at the hospital usually takes on the task of applying for the Medicaid. A social worker, or similar hospital worker coordinates everything needed to submit an application for assistance, which can sometimes be a very lengthy and difficult process. Patient Transfers When a patient is transferred from a hospital to another facility, it is a very coordinated ordeal. For the patient, there is not much involved, however, this is in thanks to the coordination efforts of the hospital social worker. There are a number of steps involved in arranging a patient transfer, much of it depends on the patient's needs. The patient's doctor puts in orders that the patient is ready for a transfer to a step-down facility. -
The social worker contacts all doctors on the patients care team to ensure they are in agreement with the transfer.
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The social worker contacts facilities that may be able to take and care for the patient. This can take a considerable, amount of time. It starts with an initial phone call, and then if the facility representative is not available you must wait for a return call. Once a facility representative is contacted, in most cases, they set up a time to come evaluate the patient. This all must be coordinated.
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Depending on the facility that is willing to accept the patient, the social worker then must obtain the ok from the patient or their family. This often involves a meeting to discuss what will be available at the facility once transferred.
Once everyone is in agreement, a transfer date is set, and the transportation must be arranged. Related: Obsessive Compulsive Disorder Facts