- Manages all aspects of discharge planning for assigned patients as follows: Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with the physician.
- Determines appropriate post-hospitalization facilities (home versus supervised living situation, board and care facility, extended –care facility, or rehabilitation facility), durable medical equipment, post-discharge nursing and/or therapist interventions, social service involvement, and need for assistance with activities of daily living.
- Interviews patients, family members and/or care givers, interface with responsible physicians, and reviews medical records.
- Identifies and resolves delays and obstacles in collaboration with the RN Case Managers, nursing and the attending physicians
- Attends interdisciplinary conferences/team meetings where appropriate to discuss patient’s home situation, level of independence and activities of daily living, home management and environment, and anticipated discharge needs for continuum of care.
- Develops and maintains cooperative relationships with hospital personnel, physicians, suppliers and insurance case managers.
- Enters data including referral for managed care patients, into Home Health System.
- Monitors activity of observation cases to see that the patient is appropriately discharged in a timely manner.
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