background in order to ensure the appropriate care is provided. “As social workers we have many opportunities to work with patients, family members and the treatment team regarding psychosocial issues, transitions of care, patient rights, advocacy and palliative care,” added John Ontiveros, LCSW, HMH Transplant social worker. “One of the most rewarding aspects of my position is the opportunity to work with the multi-disciplinary team to enhance the patient experience at Houston Methodist. Contrary to what many may think, case management responsibilities do not always end at discharge. Many times, our team follows-up with patients by collaborating with care navigators, who are responsible for post discharge phone calls to help prevent readmission. This is a very important step in easing the transition from hospital to home. “Case Management is definitely a different side of nursing, but there still are plenty of opportunities for patient contact,” said HMH case manager Shelby Wiley, BSN, MS, RN. “My role has been very fulfilling and gratifying to me. Like most of us, what I enjoy is having the opportunity to see the end result—ultimately seeing the patient return home with the support that they need.” In today’s ever-changing health care landscape, there has never been a better time to work in case management. And, the high level of patient acuity being found in hospitals nationwide only adds to the importance of having an experienced and dedicated team of case management professionals. During National Case Management Week, which runs from October 13-19, our organization would like to recognize our high performing case management team for their tremendous efforts and contributions. “It‘s obvious the Houston Methodist organization truly values what we do and what we bring to the health care team,” said Thomas. “Collectively, I think our team has over 300 years of case management experience, so we use all of that knowledge to help our patients reach the best outcome possible.”
Audrey Thomas, RN, CM, ACM, and Shelby Wiley, BSN, MS, RN
Case ManageMENT Role • Advocacy & Education – ensuring the patient has an advocate for needed services and any needed education. • Clinical Care Coordination/Facilitation – coordinating multiple aspects of care to ensure the patient progresses. • Continuity/Transition Management – transitioning of the patient to the appropriate level of care needed. • Utilization/Financial Management – managing resource utilization and reimbursement for services. • Performance & Outcomes Management – monitoring, and if needed, intervening to achieve desired goals and outcomes for both the patient and the hospital. • Psychosocial Management – assessing and addressing psychosocial needs including individual, familial, environmental, etc. • Research & Practice Development – Identifying practice improvements and using evidence based data to influence needed practice changes *courtesy of the American Case Management Association (ACMA)
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