We discharge plan, case manage and provide social work. We search for funds to provide needy patients with rides home or medications, call thrift shops for clothing or equipment, and reach out to charitable organizations to donate towards a ticket home or pay an electric bill.

We do IMs, PASRRs, transfer forms, PA reviews, Baker Acts and Marchman Acts. Chart reviews, RACs/MACs, ALJs, core measures and documentation are a part of our life. We are witness to the human condition: the elderly taking care of the even more elderly, children struggling to care for their needy parents and parents unable to ever end parenting their children.

We search for families and for people willing to care as much as we do. We plead with insurance companies, home health agencies, other hospitals and supply companies to help us help our patients.

We are gate keepers and promise keepers. Whether we touched the patient or not, once “discharged” is attached to their name, they become ours. We watch as reimbursement impacts our staffing and secretly pray that others understand how much we do that nobody even knows about. Many of us have lost staffing over the last months and years; we have learned to put our Size 8 Responsibility into Size 5 Staffing Shoe.

Despite obstacles and lack of resources, we strive to treat everyone the same as we search for alternatives and options. We try to teach others that discharge planning can begin when anyone sees the patient’s need; we so need that “vision of need” from others on the Team and so love the therapist or dietitian who shares it with us. We have “gone to bat,” “gone to battle” and unfortunately, sometimes have even “gone to court” trying to care for our patients.

It suddenly seems to me that, more than being advocates, as case managers and social workers we are such an amazing “support system” for our patients, their families and our facilities. In the old-fashioned concept of welfare workers, as case managers and social workers we impact how well our patients fare.

Happy Case Management Week to all of my colleagues!!