Does the nurse case manager help to coordinate community services for the patient?
MS: Yes, because there are patients in that program that end up with another home health, or with another hospice, so in a peripheral sense, we do coordinate those services, as well. Hopefully, we’ve taken care of linking patients with community services on discharge, but if not yet, the community outreach nurse can utilize our home health social worker, and our other team members to get some resources to people. Are you tracking what happens to that group? For example, what percentage get readmitted to some other program that you have? MS: Our data show that 30-40 percent of these patients are readmitted to one of our programs. The patient has the ultimate choice on the type of care they want, but many seem to find trust and comfort in our program. How do you support the telephone case management program? MS: Our Community Outreach program is managed by the nurse case manager, who is paid with funding through donations, and a volunteer nurse who also works in this program. We don’t bi
