Who We Are
Health care has seen many changes over the last few years, including the move to improve care coordination and help patients transition successfully to home or or their next level of care after their hospital stay. At VUMC, our patients and families come first.
Transition Management comprises RN case managers, social workers and discharge planners and is supported by our leadership team and other support staff. Our case managers and clinical social workers use advanced skills to assess and coordinate care for diverse patient populations. They collaborate and consult with a multi-disciplinary team of skilled and specialized health care professionals, as well as with patients and families, to ensure safe and effective coordination of care.
What We Do
Effective care coordination helps advance the care plan during the inpatient stay and transition patients to the most appropriate setting. The goal is to ensure a safe transition to the appropriate level of care, whether with home care or to a facility. Patients have choices in selecting a provider that will meet their needs after discharge. Our staff are experts in assisting the patient, family and team to identify appropriate are settings for the patient.
Along with the multidisciplinary team, our staff members anticipate the patient's medical needs and assess their financial resources and family support to ensure the family is on board and in agreement with the plan of care. In the inpatient setting, care coordination uses nursing and social work to assess, implement, reassess and risk stratify for patients, in collaboration with the multidisciplinary team. Our nurses and social workers, in collaboration with our support staff and team, truly impact patient outcomes and the trajectory of their clinical needs.