Providing Continuity of Care
The Case Management Department at Palms West Hospital is made up of nurses and a physician advisor, all playing an integral role in the coordination of care and discharge planning for our patients. We provide continuity of care by working with physicians, nurses, dieticians and physical therapists who all work with patients, to ensure they receive the most appropriate discharge plan to meet their healthcare needs.
Upon admittance, patients are assigned a room that meets their appropriate level of care. Once comfortably settled, one of our nurse case managers will begin reviewing patients’ charts to gather clinical information about any medical condition so a practical discharge plan can be developed, and care coordination can begin. The patients and family members will have a clear expectation of duration of stay and proactively understand the discharge process and estimated timing so post discharge care needs can be arranged and ready prior to discharge. Services such as post acute rehab, skilled nursing facility care, home health, infusion, durable medical equipment and long-term care facilities are arranged with the input of patients, doctors and family members to ensure that they meet all of their clinical and social needs. All is coordinated with insurance benefits and providers. We remain in close contact with the insurance carrier to assure that proper guidelines have been met.