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Department of Care Coordination
(Social Services)
The mission of the Department of Care Coordination is to coordinate
the delivery of quality health care services across the continuum
of care — from pre-hospital care through the patient's hospitalization
to post-hospital home care — and to modify the plan of care
for optimum benefit through the effective use of available resources
and continuous monitoring of the patient's needs. The Department
of Care Coordination consists of clinical social worker and registered
nurse teams assigned to nursing units and outpatient services
at VCU Health System's MCV Hospitals and Clinics.
Some of the responsibilities of the RN care coordinator include:
- arranging Home Health Care and skilled nursing,
- making referrals for Home Health Hospice and Home Infusion,
- assessing mental/behavior status,
- making referrals for homebound patients requiring lab monitoring,
- arranging for home durable medical equipment,
- monitoring/recording avoidable days and insurance denials,
and
- serving as liaison between hospital and insurance company.
Some of the responsibilities of the Social Worker Care Coordinator
include:
- assessing psychosocial needs and barriers to discharge/treatment,
- providing education about advanced directives,
- counseling,
- making referrals to community agencies, nursing, adult home
or shelter placements,
- coordinating facility to facility transfer and routine and
specialized transportation,
- providing referrals for financial assistance.
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