Care Management

Aligning goals, providing education, & managing care outcomes

Utilizing a patient-centered, strengths-based approach, NVRH Care Managers align patient and clinical goals, provide patient education, and manage financial and quality care outcomes in the hospital. The Care Management Department, which is a multi-disciplinary team made up of nurses and social workers, works collaboratively with the patient, their family, provider(s), hospital staff, and community-based supports to plan, coordinate, evaluate, and implement the options and services required to meet the patient’s health needs. The department also utilizes available resources to promote quality, cost-effective outcomes for the timely discharge of a patient.

NVRH Care Management services are available to all patients: daily assessment is provided to inpatients and medical social work services are provided to patients of all ages in the Emergency Department, Medical-Surgical Department, and Outpatient Services Department. Day Surgery and Birth Center receive services by consult.

Care Management services include: 

• Advocating for patient goals and perspectives
• Providing patient and family education
• Comprehensive psychological, social, spiritual, and financial assessments
• Community-based services coordination
• Insurance navigation support
• Crisis intervention and safety planning
• Fetal demise decision navigation
• Complex care coordination (short and long term)
• Referral processing, prior auth and complex discharge planning
• Navigation of End-of-Life Care decision-making