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Proper planning for your departure from The Valley Hospital ensures you receive the care and assistance you need once you leave the hospital, whether you’re discharged to your own home or someone else’s, a rehabilitation facility or a nursing home.
Discharge planning should begin as soon as possible. If your hospital stay is planned, discharge planning can begin even before your admission.
Discharge planning through Valley's Care Transitions department and its team of case managers and social workers involves:
- Assessing your physiological, psychological, social and cultural needs
- Developing a plan of care after hospitalization
- Arranging for the services you need
Case Manager Services
Every patient admitted to Valley has a case manager who can assess and plan for your needs when you leave the hospital. Case managers are registered nurses who:
- Work closely with you and your family members, caregivers and doctors to ensure you receive the best care possible
- Visit you during your stay to evaluate needs and make referrals for post-hospital care
- Can help set up home care services, working with your doctor to make sure all home care needs are met
- Work in your best interest within the guidelines set by your insurance company
Social Work Services
Depending on your needs, your discharge planning may also involve the services of social workers. Valley’s medical social workers are licensed professionals who can meet with you and your family to discuss concerns regarding your return home. They also provide referrals and coordinate services to ensure you receive a complete continuum of care.
Social work services include:
- Counseling and crisis intervention
- Facilitating adjustment to hospitalization and/or illness
- Educating and coordinating planning for long-term care
- Providing information on resources
- Networking with community, county and federal services
- Dealing with end-of-life issues
- Referring to legal services
- Coordinating discharge plans in conjunction with case managers
- Facilitating support groups
