Our case managers work primarily with patients that carry the diagnosis of Congestive Heart Failure, Heart Attack, Pneumonia, and COPD (Chronic Obstructive Pulmonary Disease.)
We work closely with the healthcare team to evaluate the health status of patients and to anticipate what types of post-hospital services may be needed.
Some of the functions of the case managers include:
- Assessing and planning with the patient to secure services after discharge (rehabilitation, custodial care, hospice, home health care, shelter, and transportation)
- Education with the patient regarding their disease process and how to stay healthy at home
- Follow up phone calls to ensure that the patient is doing well in the community after their discharge