The Case Management and Social Service Department staff at Vanguard 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 and social workers 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, skilled 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 patients in 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.