Care Coordination

Getting discharged from the hospital is a relief, but it’s only natural to feel a little anxious about how to manage your health after you leave. What kind of help will you need? What resources are available in your community to assist you? The Care Coordination team at MarinHealth can provide you with answers, advice, guidance, and support to make your transition comfortable.

Our team of registered nurse (RN) case managers, licensed clinical social workers, and care coordination assistants, all work seamlessly together to ease your transition from hospital to home. They are trained to assist you and your family in the following important ways:

1. Discharge Planning, from the Start

In order to provide a personalized care plan, we actually start planning for when you’ll be well enough to leave the hospital as soon as you are admitted. A care coordinator will meet with you to perform an initial assessment to help anticipate the needs you’ll have when you leave the hospital. The assessment will take into consideration your current health status, living situation, any medical equipment you might need, and whether you have experience with a skilled home care agency or private duty caregiver.

2. Ongoing Guidance and Support

During your hospital stay, our care coordinators also chat with you and your loved ones about any questions you might have about your care after discharge. They will assist your ongoing care team to schedule any medical tests, procedures, and care you may need after you leave the hospital.

While in the hospital, you may have to make complex decisions involving treatment or clinical ethics issues. We can help you understand your options so you can make the decision that’s best for you. Care coordinators are also available to help resolve potential communication problems between patients and their families, and staff.

3. Utilization Review

A Utilization Review is a clinical requirement that provides insurance companies and payers with the medical information they need to approve inpatient hospitalization. RN case managers perform daily clinical reviews based on standardized criteria to ensure that each patient receives the correct level of care in the hospital.

4. Referrals and Placements

Some patients will need skilled services at home such as physical therapy, nurse supervision of medication management, or wound care. care coordinators provide lists of resource agencies for patients to choose from.

If the patient meets criteria for skilled nursing placement, a care coordinator will discuss options and help get the patient accepted at a facility of their choosing. Marin County is fortunate to have many excellent skilled nursing facilities, skilled home care agencies, and private care companies.