DISCHARGE PLANNING/CASE MANAGEMENT

Discharge planning/case management begins upon a patient’s admit to the hospital.  Patients should begin thinking about their needs for the recovery period upon admission to the hospital, or in advance of an elective surgery. Tri State Hospital’s discharge planning/case management team is comprised of a social worker (SW) case manager and an RN case manager. Discharge planning/case management is a service to assist patients in arranging the care needed following a hospital stay as well as to monitor your hospital stay to ensure that optimal care is delivered in the most efficient and cost-effective manner.

The hospital discharge planner will collaborate with the patient and their family, the therapy team, and the physician to ensure that the patient’s discharge needs are identified and the patient is transitioned to the appropriate setting. The discharge planner can assist with providing information and referrals to community agencies, assist with transitions to skilled nursing facilities or long term care facilities, provide information for home care services, rehabilitative care, and out-patient medical treatment as well as providing assistance obtaining needed home medical equipment. The SW case manager collaborates with the interdisciplinary team and community agencies to coordinate care across the health care continuum.

The RN case manager works closely with the physicians and the insurance companies to ensure that the patient’s hospital stay is meeting medical guidelines and that insurance will provide financial reimbursement. Insurance regulations and strict federal and state laws require continuous monitoring of the patient’s treatment and length of stay to ensure the level of care is appropriate. The RN case manager coordinates the clinical team goals and manages the financial and quality outcomes of the care provided.

The SW case manager is also available to provide assistance with any social services needs. The social worker can meet with patients and families to provide information regarding financial issues, substance abuse issues, end of life care and grief support, domestic violence assistance and support, and assistance or short term counseling related to any mental/emotional issues. The SW case manager is also available to answer questions and assist patients with information and completion of Advanced Directives.

For more information or to request the assistance of case management services, please contact the case management department at 509-758-5511 ext. 2710 (SW) or ext. 2740 (RN).