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
Transfers can take several weeks to coordinate, and along the way, if one doctor indicates they are not comfortable with the transfer, it is stopped, at least temporarily. Coordinating A Patient's Release Coordinating a release can be a simple process, providing the patient will need no help or assistance upon their release. On the other hand, if a patient is going to need assistance, there can be an extensive amount of coordination. The social worker must ensure all of the patients, doctors are in agreement with their release. -
An assessment must be coordinated to determine the patient's needs. This usually involves an occupational therapist that can assess the physical, limitations of the patient. Then a cognitive therapist evaluates the patient's cognitive functions.
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Upon completion of evaluations, the social worker begins to line up proper assistance for home care. This is generally done coordinating with family members to be sure they are satisfied.
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There is a team meeting in which everyone involved in the patient's care agrees they can safely be released.
The social worker follows the planned release closely up until the release time. In most cases the social worker follows up for a couple weeks following the release to ensure all is well. From start to completion of the patient release, the social worker can spend a large amount of time coordinating to ensure the patients wellbeing. Related: 5 Ways to Soothe Your Feet after Working a Long Shift The coordination of multiple schedules, and determining everyone's availability to meet, can take time, and often involves multiple emails and phone calls. Transfers involving other facilities, mean coordinating with the schedules of the staff and their ability, then arranging for the patient's family to attend. It takes a very patient, and persistent person, to coordinate and arrange meeting times with what can be large groups of people. The process can be lengthy, during which time, the patient's insurer is most likely calling regularly insisting on a quick release. Coordinating home care and physical therapy can consume an entire work week, and even then, be left unfinished. Coordinators know to what means they need to go to achieve results to ensure the best possible care for the
patient. All hospitals have social workers or coordinators there are specialist in getting things done. The behind the scenes work of a patient's release generally goes smoothly, thanks to the coordinators involved. Related: List of nursing organizations Please follow us on Facebook, Linkedin, Pinterest and Twitter