The function of Care Coordination is to:
- Register patients in a timely manner while ensuring information entered is accurate.
- Assign patients from various points of entry by using appropriate aggregation and level of care.
- Assess and identify psychosocial, medical and discharge planning needs of patients and the health care services to meet those identified needs.
- Identify appropriate alternate levels-of-care settings.
- Provide ongoing communication and collaboration with members of the healthcare team.
- Practice utilization management (appropriateness of admission and continued stay).
- Practice clinical resource management (expedition of tests, procedures and referrals).
Social workers provide the following services as appropriate to the setting and individual patient needs:
- Psychosocial assessment
- Supportive counseling for patients, families and group modalities
- Discharge planning for ICU’s and complex psychosocial discharge needs
- Psycho-education for patients and families
- Crisis intervention
- Bereavement counseling
- Adoption, foster care, guardianship
- Prevention of domestic violence and abuse