On-Going Care Options

Clinical social workers help our patients prepare for discharge from the hospital and for their post-hospital care. Discharge planning often involves coordinating several services, and the social worker can serve as case manager to ensure that the patient makes a timely transfer and health adjustment from care within the hospital to alternative sources of care or self care. Post-hospital care plans may include return to home with in-home services or equipment, placement in long term care facility, or other arrangements needed at time of discharge.

The social worker identifies the patient’s discharge planning needs, taking into account the patient’s illness and treatment needs, patient and family preferences, level of care, financial resources, services/facilities available, and any special circumstances. The social worker also provides counseling to the patient and family, to prepare them for discharge from the hospital and post-hospital care.

Our Post Hospital Care Planning Unit assists our clinical social workers with discharge planning arrangements that might require placement at a nursing facility, rehabilitation center, or to transfer to another acute hospital.

Contact our Post Hospital Care Planning Unit at 1-319-356-7118.