Case Management Center

Discharge planning is a process that evaluates a patient's needs after hospitalization. Care and services may be arranged to:

• Address ongoing health care concerns;
• Ensure that patients and their families have the ability and willingness to manage their care;
• Maximize safe and timely discharges; and
• Facilitate comprehensive and well-coordinated discharge plans.

At Boston Children's Hospital, the Clinical Case Managers work with the multidisciplinary team to evaluate potential discharge planning needs from the start of a patient's admission. In some cases, they assist with proactive planning prior to a patient's elective admission to ensure assessment of and advanced preparations for post-hospital care needs. Likewise, they are available to assist with immediate post-discharge issues with care continuity and funding for medically necessary and appropriate care and services.

Activities performed by the Clinical Case Managers include the following:

• Meet with patients and their families to assess their needs, resources, and expectations for post-discharge care;
• Participate in ongoing multidisciplinary preparations for special discharge planning needs;
• Collaborate with the clinical team and patient/family to outline comprehensive discharge goals and plans;
• Initiate referrals for post-discharge care and services;
• Initiate referrals for ongoing case management and/or community resource services;
• Assist with insurance approvals for post-hospital care, medications, and treatments.