Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet the patient’s care and discharge needs.
Case managers are registered nurses (RN) and social workers (LCSW) that are specially trained to collaborate as part of the integrated care team. The case management team is an essential part of the admission process, as discharge planning begins at the time of admission. The patient, family or care givers are interviewed by the case manager to assess needs and promote discharge planning.
The case manager coordinates the multi-disciplinary care team to determine the patient’s on-going needs, and evaluate, anticipate and eliminate barriers to discharge. The case manager works with patients and families to determine the next level of care and service needs required at the time of discharge.