Medical Social Services

Counseling and intervention can be provided by the medical social worker when the home social dynamics affect the medical condition of the patient. Visit frequency determined by the patient’s physical and social needs and physician’s orders.

Services Provided

  • Psychosocial assessment/evaluation
  • Financial assistance
  • Counseling for long range planning
  • Housing/nursing home placement
  • Community resource planning
  • Contingency/emergency care planning
  • Brief therapy
  • Crisis intervention

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Time Heart Failure

Heart Failure is the leading cause of hospitalization in persons 65 and older with 3.6 million admissions per year. The disease accounts for 27% of hospital readmissions within 30 days after discharge. Almost 50% of hospital discharges readmit within 6 months.

TIME (Telehealth Intervention with care Management, Education and Empowerment) addresses the following:

Skilled Protocol:

  • Medication Reconciliation
  • Signs and Symptoms Reporting
  • Teaching of Disease Process
  • Teaching of Management Tools

Cardiocom Remote Monitoring:

  • Weight
  • Blood Pressure and Pulse
  • Oxygen Saturation
  • Peak flow
  • Blood sugar
  • Patient and Caregiver Education :
  • Understanding Disease Process
  • Sign and Symptoms Identification
  • Diet Modification
  • Understanding Medications

Benefits for Patients :

Reducing unplanned hospitalizations and emergent care. Encouraging adherence to the prescribed care plan. Improving awareness of important symptoms. Enhancing ability to stay independent and in the home. Increasing satisfaction with their care. Bringing peace of mind that their health status is being monitored

Benefits for Doctors :

Improves bottom lines by more effective in-office scheduling. Increases revenue through Care Plan Oversight. Enhances perception of quality of care in the patient. Helps making more informed decisions based on vital sign data. Monitors patient response to medications for better adjustments. Intervene early before the patient’s status declines. Improving hospitals bottom lines. Increases DRG profits by shortening Length of Stay. Creates new revenue due to higher ratios of admissions per bed. Allows cost-shifting by better allocation of higher reimbursing payers. Reduces financial liabilities due to unplanned readmissions. Improves quality reporting data by reducing preventable readmissions.