Your Stay And Discharge Plan
Healthcare is constantly changing; a patient’s care and ultimately, recovery can be delivered in a variety of settings, beyond the hospital. As a result, hospital stays are shorter, with recovery occurring in rehabilitative facilities or in the comforts of one’s home with and without visiting nursing.
At Tufts Medical Center, the patient and family are always top priority. Every patient’s discharge is unique, specially designed to meet their own needs. To meet a patient’s care needs, discharge planning starts early, sometimes prior to hospital admission or at the start of a patient’s admission.
Discharge planning involves the patient, family and/or significant other. All the patient’s healthcare providers are involved in the discharge process: your physician, nurses, nutritionist, pharmacist, physical therapist, and social worker and case manager. The coordinators of your discharge are the case manager and staff nurses. The case manager assesses each patient to determine the extent of their discharge need(s). Patients who have few needs may require a simple discharge and will transition home with the assistance of the staff nurses. Patients with more complex discharge needs will be assisted by both the case manager and the staff nurses to ensure the best possible plan for the patient and family.
Your Case Management Team
The case management team is comprised of the case manager and social worker. Their goal is to provide support for the patient/family/significant other throughout the hospital stay and during the discharge process by:
- Coordinating the elements of your hospital care
- Advocating for your personal care needs
- Explaining elements of your hospital care and discharge needs
- Working with and preparing patient/family/significant others for a safe discharge
- Assisting with and optimizing healthcare insurance benefits
- Coordinating your discharge and transition from the hospital to your next care setting
The case management team is your advocate working collaboratively with the healthcare team and planning with the patient/family to provide the right care, at the right time, in the right place/setting, in order to ensure the highest quality of care. The patient is always top priority. At any point in your stay, you can request to speak with the case manager and/or the social worker.
The essential functions/ best practices for Case Management are:
- Care Coordination
- Utilization Management
- Transition and Discharge Planning
- Denial Management
