Department of Patient and Family Resources/Case Management

The Patient and Family Resources/Case Management Department focuses on assisting the patient/client in navigating through and transitioning out of the health care system. The department consists of Registered Nurses, Social Workers, Discharge Facilitators, and administrative staff who work in collaboration with other members of the healthcare team.  Functions of the department include case management, care coordination, providing psychosocial and behavioral services, and discharge planning/care transitions.  Key objectives include:

  • Contributing to the development of the multidisciplinary plan of care with other members of the care team, focusing on the identification of needs, and the progression of care; while assuring the quality and appropriateness of care
  • Promoting the optimal use of clinical resources through the regular and ongoing communication with the care team and the utilization management staff
  • Facilitating an appropriate discharge, in accordance with the patient’s medical readiness and expected needs
  • Providing crisis intervention and stabilization in both emergent and urgent situations
  • Providing counseling services in reaction to illness, end of life care and disability issues
  • Linking patients/families to community resources

Description of Patient Populations

The Department of Patient and Family Resources serves patient populations from newborn through geriatric.  The focus is predominately serving patients/family members who are admitted to the acute hospital setting and/or receiving services in the Emergency Department.  Services are also provided in various outpatient clinics.

Patients/family members can be seen both pre-treatment or procedure, during a hospitalization and/or post-treatment or procedure for follow up.

Services/Care Rendered

Meeting the needs of a patient/client is a multidisciplinary function, requiring participation by all of the health care team.  In collaboration with the medical staff, nursing and others, members of the Case Management Department coordinate services and work to progress the patient through their plan of care.

Case Managers/Social Workers identify their cases through either a consult received, rounds with the care team, and/or triggers that flag patients to be seen, examples of triggers/flags include patients that are readmitted, patients admitted from a SNF or Hospice, or diagnosis specific triggers, i.e. stroke patients.

Patients seen by a case manager/social worker are assessed for continuum of care needs, a plan is developed and implemented as appropriate, and the plan is monitored during the patients visit/stay.

Working with the care team in a clinic or hospital the staff identifies, and when possible, offers to the patient/client services, resources, and counseling that the individual needs to create a safe, effective and efficient transition/discharge from the hospital or clinic.  Team members arrange for services that include, but are not limited to; Home Care, Skilled Nursing Facility, Transportation, Medication Availability, Behavioral Health and Substance Abuse treatment, Acute Rehab, and Regulatory reporting on potential abuse cases.

Health Care Team

The Department of Patient and Family Resource/Case Management administrative structure consists of a Director and four Managers.  The department reports to the Vice President for Nursing/CNO.

The Department consists of Registered Nurses, Social Workers, Discharge Facilitators and Administrative staff.

The Clinical Social Worker provides and coordinates psychosocial and behavioral services to her/his group of patients. She/he assesses, plans, implements and monitors a plan of care for her/his group of patients.  This is done in collaboration with other members of the medical team, i.e. physicians, nurses, case managers, PT/OT staff, pharmacists.  She/he works with the care team in a clinic and/or hospital setting to identify, and, when possible, provide the services/resources and counseling that a patient/client needs to create a safe, effective and efficient transition/discharge from the hospital or clinic. Provides his/her expertise in a crisis intervention situation. She/he also maintains a focus on the “progression of care” working with the care team on the appropriate utilization of resources/services and creating a safe, effective and efficient transition/discharge from the hospital.

The RN/SW Case Manager assesses, plans, implements and monitors a comprehensive plan of care for her/his group of patients.  This is done in collaboration with other members of the medical team, i.e. physicians, social workers, PT/OT staff, pharmacists, respiratory, dietary, and nursing.  Maintains a focus on the “progression of care” working with the care team on the appropriate utilization of resources/services and creating a safe, effective and efficient transition/discharge from the hospital.

Discharge Facilitators and other members assist the staff in their roles through many functions, including but not limited to;   providing necessary information to both internal and outside entities, answering questions, coordinating the compilation of data and invoices, arranging transportation, and preparing information to facilitate transfers.

Members of the department work closely with all members of the medical team, and with outside agencies when arranging a transfer to another facility/institution

Staff participates in care rounds on units and in clinics and facilitates team meetings with the care team, and with patients/families.

Staffing Plan

The department has staff on-site and/or on-call 24/7.  There is also a Social Worker on-call as backup and a manager on call 7 days per week.

Staff can be unit based, service based and/or clinic based, depending on the needs of the area.

The total FTE budget is 142.  73.25 Registered Nurse staff; 47.25 Social Work staff; and 21.5 Administrative ancillary.

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Jennifer Zimmerman, RN, explaining to a parent and her daughter how to use a bedside asthma action plan.