Care Coordination at KRMC is a patient-family-centered, team-based model designed to help patients and their support system navigate the ever-evolving healthcare system.
KRMC Care Coordination strives to facilitate efficient patient-centered transition of care while in the hospital and proper transition after hospitalization. Our team has 52 years of combined nursing experience, 31 years of social work experience, and additional experience in psychology, criminal justice, health science and healthcare management.
Our team consists of managers, social workers and insurance specialists. We work together to help patients and families with various needs related to hospitalization and discharge/return to care.
Our team work closely with your care team of physicians, nurses, therapists and other medical professionals to understand your unique hospitalization and/or post-care needs.
- Evaluate discharge needs such as home healthcare services and/or medical equipment
- Locate educational material and resources regarding your medical condition or other care needs
- Communicate with your healthcare team about any concerns or impacts to your overall well-being
- Provide referrals for community resources, supportive counseling and assistance related to adjusting to an illness, injury or recovery
- Help you and your family with legal needs such as durable power of attorney or advance directives
- Aid you and your family in setting up inpatient rehabilitation, skilled care or long-term care if needed
Care Management works with patient care teams to provide specialized medical care for those individuals living with a serious illness.
- Provide relief from the symptoms and stress of the illness
- Improve quality of life for both the patient and the family
- Coordinate Comfort Cares resources if needed such as offering religious advisors and family resources
What to Expect After Discharge
You may have further medical or recovery needs once you have been cleared for discharge. During your hospital stay, the discharge planning team will take time to learn about any potential discharge needs you may have, and find answers and options. Possible ongoing care options that may be discussed with you and your family include:
- Long-term acute care (LTAC): This type of facility is considered a step down from the hospital. LTAC facilities specialize in the treatment of complex medical issues.
- Inpatient rehabilitation: This program provides intense, short-term physical, occupational and/or speech therapy for a total of three hours each day. The goal is to help you return home. Please keep in mind that you may still need 24-hour assistance or supervision after discharge.
- Skilled nursing facility: These facilities provide short-term care, including physical, occupational and/or speech therapy. The level of care depends on the patient’s ability to participate. This is a less intense program and may be recommended for those who are unable to participate in three hours of therapy each day.
- Long-term care facility: This type of facility provides custodial care for patients who cannot care for themselves.
- Home health: These programs offer skilled, intermittent care and treatment for illness or injury. This may include nursing services and physical, occupational and/or speech therapy. If necessary, social and dietary services may also be provided.
- Outpatient therapy: For people who require further physical, occupational and/or speech therapy, services may be set up with our hospital team or at a location closer to home.
- Hospice: These programs are for patients and families facing progressive, life-limiting illnesses who wish to have care focused on comfort (symptom management; psychosocial, spiritual and practical support) at home or in an inpatient setting. A team of physicians, nurses, aides, social workers and chaplains provides comprehensive care through the final months of life.