When an illness, unexpected injury or surgery results in a stay at an inpatient rehabilitation  hospital, the experience is often overwhelming. Patients may have many questions, such as: How long will my stay last? Will I be able to manage at home when I am discharged? What does my insurance cover? If I cannot pay for the care I need, is there support available? If I need extra help at home, what are my options?
At Good Shepherd Rehabilitation Network, the Care Management staff expertly guides patients and their families through the rehabilitation process, educates and assists patients and families to capitalize on available resources and works to identify the answers to these and many more questions.
Good Shepherd Care Managers are professionals who have been specially trained to coordinate care in the hospital and help patients identify and access the services that will aid their transition upon discharge.
Care Managers serve three main functions:
Shortly after admission, Care Managers meet with patients and their families to conduct a thorough assessment, which helps the Care Manager gain a better understanding of the patient’s prior level of function, living situation and personal goals. Other pertinent information that may impact the patient’s recovery, rehabilitation and discharge also is assessed.
This information, along with assessments/evaluations completed by other members of the interdisciplinary team, allows for development of an individualized care plan, projected short-term outcomes and recommended length of stay. The Care Manager communicates this information to the patient and family to allow for feedback, appropriate adjustments, ongoing care coordination and discharge planning.
In some situations, financial concerns prevent the patient from being able to focus on his or her rehabilitation goals and recovery. Care Managers are knowledgeable about Medicare and other insurance providers’ coverage availability and limitations. They will work directly with the patient to provide education and will advocate with the insurance provider to maximize appropriate/available services and coverage. The Care Management staff can also educate and assist patients to apply for assistance from pharmaceutical companies, government agencies and other programs that help people in need.
Family and friends play a vital role in the rehabilitation process. In their role as care coordinators, Care Managers work with them to meet patient needs. This is accomplished through regular communication of the patient’s ongoing clinical, supervision and functional needs, the facilitation of educational opportunities with nursing and therapy staff and the arrangement of follow-up services.
Ultimately, the goal of Care Management is to help patients help themselves. Care Managers achieve this goal by educating patients to better navigate the health-care system, encouraging them to advocate for their needs and supporting their maximum independence and quality of life.