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BWH 617-732-6469; 617-732-6462
Administrative Staff:
Joanne Hogan, MS, RN: 732-4891; Martha B. Burke, MSW, LICSW: 617-732-6462;
Christine Dutkiewicz, MSN, RN: 617-732-7799
The BWH Care Coordination Department is an interdisciplinary group
of professionals consisting of nurses, social workers and community
resource specialists. The mission of the Care Coordination teams is
to coordinate the diverse aspects of patient care throughout the continuum
to achieve the highest quality and most cost-effective outcomes.
Teams are deployed along major service lines: Cardiac Services; Medicine;
Surgery, Orthopedics and Neurosciences; Oncology; Thoracic Surgery;
Women and Newborn Health and the Non-Acute team, which addresses the
ambulatory care coordination needs of an integrated delivery system.
Participation in network development with extended care facilities,
home care, community agencies and coordination with the BWHPHO is
critical.
Hours of Service
The Care Coordination Department has onsite staff available 7 days
a week. The department is open Monday to Friday, 8:30 am - 5 pm. Evenings
and weekend staff can be reached by calling the page operator. Emergency
on call staff are available after 1am Monday - Friday and after midnight
on weekends.
Services Provided
1. Preadmission/admission screening (prospective and referral based)
- clinical appropriateness and projected LOS (length of stay)
- financial clearance and coordination of benefits
- psychosocial risk (abuse, guardianship, advance directives)
2. Monitoring and oversight of plan of care
- communications: team and patient/family, payer and community
- clinical appropriateness, authorizations and approvals
- utilization management
- observation status/admit-to-observes (ATOs)
3. Patient education and staff support: continuity/consistency of
the plan of care; communications among providers and patient/family,
payer and community; psycho-educational support groups for patients/families
4. Discharge planning: communications among patient/family, team,
community, payer, primary care physician/outpatient care coordinator/hospitalist.
Note: Many insurance plans require prior approval and authorization
for any services outside the hospital (e.g., VNA, transfer to ECFs
and special durable medical equipment). It is essential that as much
time as possible be allowed for patient/family teaching, appropriate
referrals and coordination of patient care.
5. Care improvement initiatives
6. Psychosocial intervention (types of referrals):
- o patient/family adjustment to illness/hospitalization
- discharge planning needs, referral to rehabilitation, chronic,
nursing home or VNA
- home care needs: homemaker, meals on wheels, medical equipment,
respite or hospice care
- utilization management: concurrent review, continued stay denials,
ATOs
- insurance/financial issues
- domestic violence
- legal or guardianship issues
- vocational/educational issues
- bereavement/loss
- psychiatric issues (in collaboration with Psychiatry)
- child, disabled or elder abuse
- sexual abuse or assault
- promotion of and education regarding organ donation
7. Obstetric cases: high risk pregnancy; adolescent pregnancy; lack
of prenatal care; presence of abuse/neglect/drug exposure for newborns
and their families; difficulty adjusting to pregnancy/parenting; post-partum
depression; fetal demise; adoption.
8. DRG Assurance Program
Nurses are assigned to review medical records to insure that physician
documentation accurately reflects the condition of the patient with
regards to severity of illness and co-morbid conditions. When indicated,
requests are made to physicians to further clarify documentation.
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