The Quality Resource Management Department staff at Weiss Memorial Hospital use a case management system to coordinate the planning of patients' post-hospital care.
Case managers at Weiss combine the skills of nurses, social workers and health information coders to assess patients' physical, emotional, social and economic situations. These individuals work closely with the patient, family, physician and health care team to determine the post-hospital care that best meets the patient's needs.
Some of the functions of the case managers include assessing and planning with the patient to secure services after discharge (rehabilitation, custodial care, hospice, home health care, shelter and transportation), and consulting with physicians and the health care team, starting at the time of admission. Consultations are made to determine care and discharge plans, the working diagnosis and if there are any barriers to discharge.
The case managers are assigned to specific medical-surgical areas of the hospital and help cover the intensive-coronary care unit, emergency department, and admitting department.
All inpatients and observation patients are reviewed at the time of admission to ensure that they meet inpatient admission criteria. Also assessed at the time of admission are potential barriers to discharge.
Patients are continually reviewed throughout their hospitalization to ensure that they are discharged to the appropriate setting at the appropriate time.