Social Services

Promoting patient, family, staff and physician satisfaction through the efficient coordination of patient care, discharge planning and smooth transition of care throughout the continuum is the focus of the Social Work and Case Management Department at Elliot Hospital. As part of the multidisciplinary team, we assist both patients and families as they decide how they will maintain their quality of life and regain an optimum lifestyle. Our team includes of both Master Prepared Social Workers and Nurse (RN) Case Managers.

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Social Workers

Social Workers

Social workers are trained to help people find solutions to many changes faced by healthcare challenges. We accomplish this through a unique combination of counseling and direct connection with the network of community resources.

Services available to both Inpatients and Outpatients and their families include:

·      Crisis intervention

·      Coping with illness and other life stressors

·      Financial counseling especially as it affects healthcare and the changes that occur with life changes

·      Enhancing communication with the medical treatment team to enable patients and families to be active partners in their own healthcare

·      Accessing hospital and community services

·      Helping to sort through available options that address a range of family issues, including caregiver and parenting support addictions and counseling.

·      Advance Care Planning - Social workers are available to assist in the execution of Advance Care Directives either while in the hospital or as a community service. For additional information on Advance Directives, as well as the most recent forms, please visit the Foundation for Health Communities website at: www.healthynh.com.

Social workers assess patients with social, emotional, interpersonal and socioeconomic issues. Areas of assessment include but are not limited to:

·      Adjustment to chronic and catastrophic illness

·      Adjustment to procedures and treatment

·      Ability to follow medical regimen

·      Family functioning and communication

·      Social and/or financial concerns

·      Personal safety including abuse, neglect, violence. Social workers are legally required to report suspected cases of abuse and neglect of children, the elderly and disabled adults.

·      Mental illness/emotional distress

·      Substance abuse

·      Adjustment to loss/bereavement

Nurse Case Managers

The case manager is a registered nurse who reviews your plan of care while you are in the hospital. The case manager ensures that your care is timely and coordinated among all members of the healthcare team. Some functions of the case manager include:

·      Overseeing the care plan so that care is efficient and coordinated among the healthcare team

·      Communicating with your insurance payer to review your plan of care and ensure that your care is covered while you are in the hospital as well as clarifying exactly what your healthcare plan covers for discharge planning needs.

·      Discharge planning to include assisting you with setting up home care, durable medical equipment, short-term skilled needs, acute rehabilitation and community resources.

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Hours of Operation:

Social workers and case managers are on-site 8 a.m. to 4:30 p.m. Monday through Friday, social workers and case managers are available on all of the nursing units. They may also be accessed through walk-in services and scheduled appointments. Please call 663-2338 to set up a scheduled appointment during business hours.

There is a social worker and/or case manager in the Emergency Room until 11pm on weekdays and is available for emergent needs on the nursing units. There is also a social worker on-call for emergencies after hours.

Discharge Planning

When does discharge planning begin?

Discussions about discharge planning begin upon admission to the hospital. We will talk about your diagnosis and the estimated amount of time that you may be in the hospital. We will ask you how you are managing at home now, and who will be able to help you, if needed, when you return home.

You and your significant other should be thinking about discharge needs as well and let the nurse know about your concerns when you enter the hospital. Sometimes it takes time to arrange needs after discharge so we need to start these as soon as possible after admission.

If you are planning an upcoming hospital admission and think you may need services upon discharge such as home care or skilled nursing care, call your insurance company to determine your benefits as to which community agency/services they will cover. It may help make the transition less stressful for you and your family.

How do I know how long my stay in the hospital may be?

Your health care team will discuss your goals for discharge and your progress. We strive to ensure that you know twenty-four hours in advance whenever possible when you will be ready for discharge. However, if you are admitted to observation level of care, it is expected that you will be discharged in less than twenty-four hours.

Is there a standard discharge time?

Because of the growing need for hospital beds, please plan your departure before noontime. To avoid waiting, it is important that you make arrangements for your discharge and transportation home as much in advance as possible. Please let the nurse know in advance if you need help in setting that up.

FOR OUR MEDICARE PATIENTS: At Elliot Hospital we want to make sure you know…

When you must stay in the hospital for care, there are two types of admissions: “Outpatient Observation” and “Inpatient”. Medicare benefits vary according to the type of admission. Here’s how they vary:

OUTPATIENT OBSERVATION:

· When your doctor wants to observe you in the hospital for a short period of time, perhaps up to 48 hours, he/she may admit you as an “outpatient observation” patient

· This admission status may be used when your doctor wants to see how you are doing before deciding whether or not you are to be admitted as an “Inpatient”

·    An “Outpatient Observation” admission is covered under your “Medicare Part B” benefits BUT, has some limitations

·   Medicare Part B benefits do not pay for any medications that you take or use by yourself while you stay in the hospital as an “Outpatient Observation” patient- these medications include pills, creams, inhalers and insulin if you are a diabetic

·   To save you money we suggest that you ask your doctor or nurse if you can use your own medications from home, if you will be taking those same medications while you are in the hospital

INPATIENT:

·    Your doctor will register you as an “Inpatient” when you need to be in the hospital for a longer period of time, such as when you have certain types of surgery

·    Your admission status may change from “Outpatient Observation” to “Inpatient” if you require a lengthier stay than originally anticipated

·    An “Inpatient” admission is covered by your “Medicare Part A” benefits, als· called “Hospital Insurance”

·    All medications are generally covered by “Medicare Part A” as of the date your admission status changes from “Outpatient Observation” to “Inpatient”

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