DRIVE
TO
Patient-Centered Excellence
22
DRIVE
TO
Patient-Centered Excellence
23
Care Transitions – Case Management/Social Work
Our care transitions team is available to help you and your family solve
problems caused by your hospitalization or illness.
The
case manager
is a nurse
who evaluates the medical
condition and potential needs
at home. He or she works with
the social worker to obtain
approval from the health plan
and ensures that you have
the services, equipment and
supplies you need.
The
social worker
can provide you and/or your designated caregiver
with your options, choices and assistance in obtaining home care,
skilled nursing care, adult services, hospice care and other community
services you may need upon leaving the hospital. You social worker, in
conjunction with your doctors and nurses, will help you arrange your post-
hospital needs before you leave the hospital to ensure that you receive
appropriate care.
If you wish to speak with the social worker or case management
nurse assigned to your unit, please contact your nurse or physician,
or call
718-960-6101
. If you require any assistance, contact the
Patient Representatives
at
(718) 960-6121
or
6353
.
Discharge
Shortly before your discharge, you will receive a “Discharge Notice.” If
you wish, we will meet with your designated caregiver to discuss your
care plan before your discharge or transfer to another facility. If you feel
you are not ready to leave the hospital, the notice will explain when and
how to appeal to the health plan for extended services. If you have any
questions, please contact the assigned nurse or the review agent listed
on the notice.
Planning for Your Discharge
The hospital’s discharge time is 11:00 am
unless your physician indicates otherwise.
Before you leave, make sure that your
nurse or doctor has given you written
instructions about your care at home.
If you have any questions, please do not
hesitate to speak with your nurse before
leaving.
You should be given a prescription
by your doctor or nurse if you require
medications.
You should also know how and when to make a follow-up appointment
with your doctor or clinic. If an appointment has been made for you, be
sure you know the appointment details, including locations.
Your Bill
If you think you will have trouble paying your hospital bills, you may
qualify for a discount. For more information or to apply for financial
assistance, ask for a visit by a hospital financial counselor or call
(718) 960-3812
.
AFTER you leave the hospital, you will receive an itemized statement
of hospital charges. If you have any questions related to charges shown
on the statement, please contact the
Patient & Family Service Center
at
(718) 960-6600
or
6605
.
