Care Management

Care Management

Social work and care management services are available to the patients of Firelands Regional Medical Center acute care including the cancer center and ER, inpatient rehabilitation, home health, and outpatient services.

Social workers and care managers collaborate with physicians and hospital staff to provide disease management and social services intervention for both inpatients and outpatients. The purpose is to develop an awareness and understanding of the psychosocial effects of illness and injury, to promote patient and family adjustment, and to develop a discharge plan and assist in providing continuity of care.

Objectives of Care Management

  • To develop a plan for continuity of care by collaborating with patients and residents and, as appropriate, their families, physicians, other hospital staff and community agencies. This plan of care shall address the efficient use of resources, timeliness of intervention and appropriate disease management.
  • To provide the opportunity for patients and families to deal constructively with emotional and social implications of their medical condition and to develop effective coping skills through patient counseling and education. An example of this would be assistance with information regarding advance directives.
  • To facilitate the patient's and family's understanding and acceptance of placement and other discharge planning activities.
  • To assist the patient and family in obtaining the necessary services and equipment from community agencies and increasing their knowledge of community resources.
  • To assist medical personnel in recognizing the impact which the emotional and social environment has on physical conditions.
  • To act as a liaison between the hospital and relevant community agencies.
  • To coordinate precertification and insurance activities necessary for payment of healthcare services and participate in denial management and insurance claim appeals.

Procedures

  • Social work and care management staff will abide by professional codes of ethics, state regulations and laws, other related statures as relevant and appropriate to the scope of social work or nursing practice, and hospital policies and procedures.
  • Social work and care management staff will be encouraged to attend relevant seminars and other continuing education activities to enhance their skills and abilities as social workers.
  • Referrals can be made to social work or care management services by physicians, nurses, other hospital staff, patients and their families, clergy, community agencies, or any other individual or organization concerned with the patient's welfare.
  • The social workers or care managers will begin discharge planning for the patient within a day after admission if the patient's diagnosis and socioeconomic situation warrant such intervention or an order is received.
  • Social work and care management will work closely with other hospital departments and community agencies to maximize recovery and emotional health of Firelands Regional Medical Center inpatients and outpatients. This may be done through multidisciplinary team meetings, advocacy or other appropriate interventions to assure a safe and appropriate discharge plan.
  • Documentation of intervention will be placed on the patient's medical record.
  • Statistics regarding services are kept by the department director.