Case Management Center
Discharge planning is a process that evaluates a patient's needs after hospitalization. Care and services may be arranged to:
- Address ongoing health care concerns;
- Ensure that patients and their families have the ability and willingness to manage their care;
- Maximize safe and timely discharges; and
- Facilitate comprehensive and well-coordinated discharge plans.
At Boston Children's Hospital, the Clinical Case Managers work with the multidisciplinary team to evaluate potential discharge planning needs from the start of a patient's admission. In some cases, they assist with proactive planning prior to a patient's elective admission to ensure assessment of and advanced preparations for post-hospital care needs. Likewise, they are available to assist with immediate post-discharge issues with care continuity and funding for medically necessary and appropriate care and services.
Activities performed by the Clinical Case Managers include the following:
- Meet with patients and their families to assess their needs, resources, and expectations for post-discharge care;
- Participate in ongoing multidisciplinary preparations for special discharge planning needs;
- Collaborate with the clinical team and patient/family to outline comprehensive discharge goals and plans;
- Initiate referrals for post-discharge care and services;
- Initiate referrals for ongoing case management and/or community resource services;
- Assist with insurance approvals for post-hospital care, medications, and treatments.