Medical Social Workers
Our exceptional medical social workers provide a critical function to assist patients and their families at most vulnerable moments during recovery with health-related problems and concerns. They also help patients access financial and health insurance coverage.
The comprehensive goal is to safely transition high-risk patients from an acute or post-acute setting to home, preventing unnecessary rehospitalization by consistently delivering improved patient outcomes and reduced cost of care among complex patients through our disease management model providing a set of proven interventions and goals to promote positive outcomes.
Disease Management
Fundamentals bases the Joint Commission guidelines foundation in prescription drug compliance. By incorporating these principles, 30day readmission mitigation occurs by empowering the patients on the proper use and knowledge of Medications and the importance of adherence.
Transitional Care Model
Coordinates health care interventions and communications systems for defined patient populations where self-care efforts can be implemented. Our DM empowers individuals to manage their disease process and prevent complications from decline, guiding the patient to reach their optimum level of wellness, self-management, and functional capability.
Medication Reconciliation
Provides comprehensive post-discharge planning with home care follow-up for chronically ill high-risk older adults hospitalized for common medical and surgical conditions. An alarming rate of one in five Medicare beneficiaries rehospitalized within 30days of being discharged back into the community.