Case management services are available to every hospitalized patient and family. Your case manager will work closely with your physician, nurse, and other members of your health care team (physical therapy, dietary, social work) to be sure that you are receiving the services you need during and after your hospital stay.
Assisting You During Your Hospital Stay
Anna Jaques Hospital Case Managers are specially trained registered nurses and social workers who are available to patients throughout their hospital stay. The case manager will visit you and your family early in your hospitalization. Together with you physician, the nursing staff, and other members of your health care team, your case manager will:
- Participate in developing a plan of care that includes you as the primary decision maker
- Assess your needs for care during your hospital stay, as well as after you are discharged
- Represent your interests, act as a patient advocate and communicate with your health care team, to assure your individual needs and goals are met.
Case Manager Services
Whether you need assistance communicating with your physician or help coordinating multiple health care services, your case manager can help you arrange for the following services:
- Acute rehabilitation
- Short -term rehab
- Nursing home placement
- Respite care
- Home Care/homemaker services
- Private pay companion services
- Home IV therapy
- Outpatient physical, occupational & speech therapy
- Emergency response services
- Hospice care
- Oxygen therapy
- Medical equipment
- Meals on Wheels
- Coordination & referral to Early Intervention
- Support groups & other community resources
- Information on Medicare coverage & benefits
Social Worker Assistance
In addition to case managers, we provide social workers as resources and advocates for you, your family, and the medical staff. Social Workers can provide the following services:
- Support and counseling to assist you and your family with the emotional and physical stresses of illness, injury and post-hospital care.
- Information and assistance with forming advance directives.
- Coordination of transfers to other facilities for treatment related to substance abuse & mental illness
- Information on financial assistance programs
- Education and referral to community agencies & support groups
- Referral coordination for adoption and foster care placement
Assistance After Discharge
Your case manager is available to help you even after you leave the hospital. It is important to call your case manager if any of the following situations occur:
- You did not receive a scheduled follow-up visit from the home care agency.
- Your equipment did not arrive as scheduled.
- You discover that you are in need of more help than you anticipated.
Additionally, as part of our service we may call you after discharge to confirm that your discharge needs were met.