Social Work - Integrated Care Management

Mission and Goals

Our mission is to assure that each patient receives timely, effective, efficient care, at the appropriate level and with appropriate resources, and to provide psychosocial assessment and intervention for patients and families with social, psychological and/or environmental needs. These needs may be related to future or current admission, diagnosis, medical treatment and discharge.

We intend to do everything possible to make sure that you receive the right care in the right place at the right time. This includes assessing your needs for prior to be being discharged from the hospital. Integrated Care Management works along with your physician, the healthcare team and your insurance company to make sure you receive the right care once you leave the hospital.

Preparing For Discharge

At the beginning of your hospital stay, the Integrated Care Management Department will assist you, along with your physician, primary care nurse, clinical/financial staff, and insurance provider to identify your inpatient and post-hospital needs.

Your Integrated Care Management team member will help you with the following:

• Daily (or as needed) reviews with your commercial/HMO insurance provider regarding your admission, length of stay and use of hospital resources (such as X-rays, stress tests and consults for services that can be done as an outpatient).
• Quality of care concerns (these are forwarded to the hospital’s Quality Improvement Department). Note for Medicare/Medicaid patients: A hospital physician advisor will review any quality issues you may have to ensure compliance with federal and state regulations.
• Questions regarding your Medicare/Medicaid rights and the appeal process. Integrated Care Management is available at extension 1550 to answer these questions for you or your family members.
• When appropriate the Integrated Care Management team member may provide referral information for community resources regarding community case management, housing, support groups, crisis counseling, and mental health programs.
• Contacting other clinical staff and community providers to arrange appropriate and community and home care services such as:
  • Acute and sub-acute rehabilitation
  • Nursing home care
  • Visiting nurses for skilled nursing needs
  • Home health aides for medical needs
  • Home physical therapy
  • Home respiratory therapy and equipment
  • Home IV infusion therapy
  • Durable medical equipment
  • Medical alert systems.

Staffing & Hours of Operation

Integrated Care Management Services at St Joseph Medical Center are provided by registered nurses (RN) and social workers and other specialists.

• Most inpatient units are assigned one or two staff members, who may be an RN or a social worker. Integrated Care Management Services are provided:
  Monday – Friday: 7:30 a.m. - 4:30 p.m.
  Saturday: 8 a.m. - 4:30 p.m.
  Sunday 9 a.m. - 5:30 p.m.
• In the Harry and Jeanette Weinberg Emergency Department
  An access care manager is available in the Harry and Jeanette Weinberg Emergency Department from 7 a.m. to 10:00 p.m. daily.
• Integrated Care Management support staff arranges patient transportation, coordinate clerical and data entry functions in support of the clinical review and denial processes, maintain various databases, and provide administrative clerical support.

Agencies that may be helpful in providing further information about your care and benefits

Centers for Medicare and Medicaid
Medicare Service Center: 800-MEDICARE (800-633-4227)
Medicare Service Center TTY: 877-486-2048
Report Medicare Fraud & Abuse: 800-HHS-TIPS (1-800-447-8477)

Social Security, Disability Issues, or Supplemental Security Income
Social Security: 800-772-1213

Maryland Medicaid and other Medical Care Programs:
410-767-5800 (1-800-492-5231)