CM model makes good use of team members’ talents
CM model makes good use of team members’ talents
The following is an inpatient case management model for AIDS patients, broken down by role, that has been used effectively at Saint Vincents Hospital and Medical Center in New York City:
RN Case Manager
- Performs admissions and concurrent utilization management, including insurance calls.
- Tracks data, e.g., variances in patient care and systems standards.
- Facilitates daily rounds and team meetings.
- Makes referrals to certified home health agencies, department of AIDS services for home care services.
- Orders transportation, equipment, and supplies.
- Alternate level of care notification.
- Issues hospital-issued notice of noncoverage letters.
Social Worker
- Completes screens.
- Participates in daily rounds and team meetings.
- Collaborates with community agencies.
- Initiates referrals to community agencies as needed.
- Provides crisis intervention, advocacy, counseling around impact of illness on the patients/significant other, bereavement, domestic violence, sexual assault, child protection, substance abuse, and patient education.
- Facilitates discussion around health care proxies, guardianship, and do-not-resuscitate orders.
- Provides financial assessments and referrals to entitlement programs.
- Maintains contact with patients through their first follow-up medical provider appointment, post-discharge.
- Refers patients to long-term and subacute placement.
Shared responsibilities
- Assess each patient.
- Identify and communicate with prior and future providers of medical and psychosocial services.
- Assist physicians in completing discharge planning forms.
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