Have you ever been to a hospital, perhaps as a patient or a family member, and felt overwhelmed, or lost in the vast complexities of the healthcare system? Anyone who first visits a hospital feels this way. Where is my doctor, nurse, or case manager? What are they doing? What’s going to happen? When are we getting out of here? Who’s in charge? Are they ignoring us? Do they even know we’re here?
Case Managers are the glue that hold the healthcare system together. Without them, the system would fall apart in hospitals and nursing homes. These are the professionals through which all the care and efforts of all the medical professionals gets funneled. They keep in touch with the Doctors, nurses, therapists, and family members, and plan the entire facility visit. This process starts from the moment a patient is admitted and is constantly updated.
These professionals are typically nurses that are certified and work in hospitals and nursing homes, but you will also find social work case managers in Home Health Agencies, Home Care Agencies, Assisted Living facilities, Independent Living Facilities, Adult Day care organizations, and Community Care retirement communities. Geriatric Clinics and Doctors often use social work case managers as well.
Your hospitals case management team will help the medical team, along with the family, to establish goals, communicate needs, and connect people with the valuable resources they need during and after the hospital or facility stay. Think of this person as a trail guide, leading you through a vast forest of information and people, to guide you through and help you arrive at your ultimate destination: a safe discharge home with a better quality of life.
The typical duties of a case management professional include:
- Managing the charts and daily activities of about 20-30 patients per day
- Daily reviews of estimated length of stay and potential discharge (utilization review)
- Responding to delays and setbacks and reconfiguring care plan and discharge dates.
- Visiting clients with the Doctors, Nurses and care team doing “rounds.”
- Facilitating communication between the family and the Medical Professionals
- Planning the transition to home, setting up resources and referrals
- Monitoring patient outcomes after discharge
- Insuring payers and vendors provide authorization for any care, equipment, or services that are covered by insurance, Medicare, or Medicaid
To get the most out of the healthcare system and ensure the best quality of life, it is important to know who this person is, and be prepared with a list of questions:
- Who are the medical professionals we’ll be working with?
- How can we reach them?
- Who are the vendors that we need to be in touch with and what is their contact information? (Home Health, Home care, Durable Medical Equipment, Therapists, Dieticians)
- What kind of after-care will we need and who can you recommend for that?
- How can we reach you if we have questions or concerns? When are you available?
If you are going to need medical care at home after discharge, the case manager will usually assign a Home Health Agency to do that. But it is your choice to decide which company to choose, you don’t have to go with the one the hospital suggests. Also, if you’re going to need additional help with dressing, grooming, bathing, meal preparations (all the activities of daily living), the hospital discharge team should have 2-3 suggestions for you of Home Care agencies in your area.
Harmony Home Care works closely with all the hospitals in the Greater Sacramento area, and is always a choice for you to consider. Please call us anytime for a free consultation.