Services in:
The Nursing Home/Rehabilitation Service

The role of the care manager is to review the admitting criteria and the length of stay and care provided. If the entry into the facility is covered under your Medicare benefit nursing and therapy will be an important part of your success to return to an acceptable level of functioning. The care manager will speak to the nurses and therapists as well as review the medical records. An additional physician or specialty support will be reviewed and facilitated as needed. There will be a collaboration with the facility social worker to attend care conferences, review discharge planning or look at long term care needs to include financial planning. The care manager will also be actively involved in reviewing the success of skilled therapy. In the event your family member is permanently relocated to a nursing facility our care managers will ensure care is appropriate and their needs are being addressed.

Services Include:

  • Use of care manager knowledge of community skilled nursing facilities to find optimal rehabilitation.
  • Facilitate Medicare-covered days for rehabilitation.
  • Educate families on visiting someone in a nursing facility/practical suggestions.
  • Advocacy regarding the rights of a long term care resident.