Post Surgical Care Management
Specially-trained patient care coordinators and social workers work closely with the patient, family, physician and health care team to determine the post-hospital care that best meets the needs of each patient.
The Care Management team helps facilitate communication and care, as well as coordinating resources. Patient Care Coordinators assist with discharge plans and provide clinical updates to insurance companies. They continually review a patient's stay to ensure that he or she is discharged to the appropriate setting at the appropriate time.
Licensed Social Workers
Licensed social workers help educate the patients and families about resources available to a patient after he or she leaves the hospital. They can also assist with arrangements for home services, such as home care, Meals-on-Wheels, and medical equipment. When needed, social workers help arrange for nursing home placement and educate families about the options of skilled nursing facilities. In addition, they educate patients and families about Advanced Directives (Living Wills, and Durable Power of Attorney for Health Care).