Case managers and social workers are embedded throughout the Sidney & Lois Eskenazi Hospital. Staff members in this interdisciplinary care team help patients with insurance needs, to get connected with resources, to navigate the health care system, and to find solutions to social and medical needs.
Transition Support
Eskenazi Health has a robust discharge planning team consisting of highly skilled RN case managers, medical social workers, pre-certification nurses, pre-certification technicians and transitional planners with the singular focus to navigate patients through the continuum of health care. Team members work alongside physician, nursing, and rehabilitation partners to help patients navigate complicated financial and social limitations during hospitalizations. Staff also works with the patient’s families and outpatient care teams to ensure a smooth transition to the next level of care, be that a rehabilitation facility or home. The Transition Support team efficiently assists patients to the correct level of care including resolving financial and other social barriers though innovation and connecting needed resources while educating patients to ensure success with care plans.
Intensive Care Management
Nurse case managers and medical social workers meet patients where they are in the community. Staff members in this interdisciplinary care team work together to help patients navigate the health care system; connect to health insurance, other funding sources and community resources such as food and housing; and find solutions to their identified social and medical needs in order to stay healthy at home. This is accomplished by advocacy, care coordination, disease and medication education, and skill building to increase independence.
Connections
The Connections team serves the Eskenazi Health network 24/7 as the frontline staff answering calls for all the outpatient networks including, but not limited to, primary care and specialty care clinical areas. This telephone access provides patients an access point to their providers and 24/7 availability to receive a triage assessment and recommendations by a skilled nurse on the Connections team. Connections nurses also support Sidney & Lois Eskenazi Hospital as facilitator of critical workflows of hospital activations for STEMIs, strokes and IR cases and as point of contact for outside requests to transfer patients to Eskenazi Hospital for care. The collaborative workflows between call center staff and the provider network support our patients in navigating the outpatient spaces within the larger Eskenazi Health network.