Care Management

Planning for Your Care after Hospitalization

Care Management and Social work departments at many hospital can help guide patients and their families through their hospital stay. They can assist with insurance questions, discharge planning and many of the emotional needs.  Patients often have continuing care needs post hospitalization. Care management can start planning and having these discussions with family and patients on day one of the hospital stay. This allows time for education concerning the options for the patient and also assessing their ongoing needs.  The physician and care managers work together with patients recommending services such as home healthcare, subacute care, nursing home placement and rehabilitation when appropriate and if the patient meets specific criteria for such placement. Families are always encouraged to participate in these discussions.  Ultimately the goal is a safe discharge to a place when the patient is medically stable for discharge so that the most appropriate healthcare can be continued or the patient’s recovery.  There are Federal and State regulations in place that hospitals are required to abide by pertaining to payment for medically necessary services.  Physicians discharge patients who are deemed to no longer need hospital care.

The Care Manager often arranges home care services before the patient is discharged from the hospital. If a patient defers any home care before discharge, and then services are needed after discharge a community referral is made by the physician

If extensive care is required at home, the patient/family may choose to pay privately for services. Medicaid may also cover additional services, based on an evaluation by a medicaid nurse . A person is eligible for medicaid depending on their income and financial assets.