Overview of Our Case Management Program
During you hospital stay you may have a visit from an RN Case Manager. The RN Case managers helps support your care while you are in the hospital and will help with your discharge needs. You and your family may work with the RN Case Manager to assist with identifying needs you may have. Our nurses are available in each hospital unit to assist with a safe discharge plan in collaboration with your health care providers.
Your RN Case Manager can secure services for home health care, equipment at home or other post-acute care needs such as rehabilitation, home infusion, hospice or inpatient skilled nursing care. The Case Managers work closely with Social Workers so they can assist with identifying community resources to help you remain independent in your home and support services to maintain or improve your quality of life.
It is important to note that Case Management will make every effort to support the discharge needs and agencies or facilities of your choice; however, it also is important to know that it may not always be possible due to your medical needs, your insurance benefits and their preferred provider network, or when services are needed. The RN Case Manager will ask for a few choices of providers you may be interested in if needed.
Patient and Family Responsibilities
- Here are a few important things that you can do to help us support you or your family member:
1. Have the patient's most recent health insurance card with you at time of admission
- 2. Discuss the discharge plan with your physician and us, your understanding, and your preferences
- 3. Don’t hesitate to ask questions or to seek clarification - we are here to help
- 4. Plan for transport needs by “checking out” services at the earliest possible time
- 5. Take an active role in your discharge – Plan on leaving by 11am the day of discharge
- 6. Ask us for the expected date of discharge
- 7. Discuss the discharge plan regularly with your doctor, nurse, and/or RN Case Manager
Your attending physician is responsible for determining your discharge readiness. On the day you leave the hospital every effort will to discharge you by 11 am. . Please notify your family or friends of your intended discharge so arrangements can be made for someone to drive you home. If you need assistance in making transportation arrangements let your nurse know.
Here are some services …..You May Need at Discharge
Please note that each hospital visit is different and your physician would need to order the appropriate service for your care. The coverage you have may differ by diagnosis and by care level.
A complete range of home IV therapy and nutritional services, such as antibiotics, total prenatal nutrition, pain management, IV fluid hydration and chemotherapy, are available. These services provide viable, cost effective alternatives to an extended hospital stay. If such supplies are necessary, the Case Manager will make these arrangements.
Home Medical Supplies
When you are ready to leave the hospital, you may find there are medical supplies you will need once you are home. Various companies provide a broad range of durable medical equipment, oxygen and respiratory equipment and medical-surgical supplies in the home environment. Supplies include a variety of wheelchairs, beds, ambulatory and bathroom aids, and oxygen and respiratory equipment. Your Case Manager will make these arrangements if necessary.
LTACH (Long Term Acute Care Hospital)
Long term acute care hospital (LTACH) is defined as medical care provided to patients who meet acute care criteria and require hospitalization for a time period generally greater than 25 days. You may be transferred to a long term acute care hospital when you are medically stable and do not require the critical care resources found in short term acute care hospitals. Your Case Manager will make these arrangements if necessary.
Acute Rehabilitation and Skilled Nursing Facilities
Many people find that going home directly from the hospital is not the best option for them. They may require further medical monitoring, extensive teaching, specialized care or rehabilitation. There are a number of choices in our health system for both Acute Rehabilitation programs and Skilled Nursing Facilities. Your Case Manager will make these arrangements if necessary.
Insurance Coverage/Payment
As you may or may not know, Medicare, Medicaid and all insurance companies set guidelines to determine whether or not an individual needs hospitalization. Case Management is very familiar with various insurance guidelines and our nurses are in contact with many payors to seek authorizations.
Case management nurses are in communication with your physician to facilitate a discharge in accordance with his or her request and your insurance company's guidelines. Remember, only your physician can write a discharge order.
Freedom of Choice
You have the freedom of choice. You are an integral part of your health care team; therefore, you are free to choose your own Post-Acute Provider. Please know that your case manager will provide you with a comprehensive list of providers for your choice. There may be limitations to your insurance coverage that you have signed up with to restrict coverage based on the plan you have chosen to participate in. Your RN Case manager will provide you with as much information as possible at the time of referral.