The Care Coordination and Disease Management Department (CCDM) works with direct patient care providers including physicians, nurses, therapists, etc. to coordinate the patient's care.
CCDM staff facilitates communication between physicians and insurance companies in an effort to promote quality, cost-effective outcomes.
Our interdisciplinary team focuses on early identification of individual patient needs, discharge planning and the daily evaluation of patient progress toward specific outcomes. A comprehensive discharge plan is developed that addresses the need for patient placement in a facility, palliative or homecare services, and behavioral health needs. Within 72 hours of discharge from the hospital, a nurse will contact the family to ensure all arrangements have been made and the family and patient understand physician orders, medications, etc.
Our team includes:
Care Coordinators (nurses or social workers)
- Screen all patients on admission
- Provide ongoing review of medically complex patients
- Assist interdisciplinary team with discharge planning of medically complex patients
- Monitor clinical processes, quality and efficiency
Clinical Social Workers
- Address needs of patients with complex psycho-social issues
- Assist/refer patients who need financial assistance
- Manage medical/legal issues and provide counseling
- Mediation and patient advocacy
- Conduct concurrent review of medical necessity
- Provide payors with clinical information
- Perform concurrent review of physician documentation
- Review all patients in observation status and write admission status orders
- Report quality events
- Provide education and consultation services
- Includes Diabetes Educator and Wound and Ostomy Care Nurses
To contact Care Coordination/Disease Management, call 928 773-2220.