Case Management, Discharge Planning, and Social Work

Discharge Planning for a Smooth Transition

Effective discharge planning is a cornerstone of Ciena Healthcare’s rehabilitation and short-term nursing care philosophy. The goal is for guests to be well-prepared for the transition from one of our rehabilitation communities to their home, assisted living, nursing care, or another healthcare setting. A carefully crafted discharge plan prevents complications that may derail recovery or result in a guest failing to get the necessary follow-up services.

Our discharge planners provide:

• Personalized care plans: A detailed plan outlining the care a guest will require at home or in another care setting, including medications, follow-up appointments, and therapy.
• Home care arrangements: Assistance in organizing home healthcare services or outpatient therapy sessions to ensure guests continue making consistent progress in their recovery after leaving our community.
• Equipment and medication management: Our planners help families secure the necessary medical equipment and supplies, as well as provide guidance on medication management.
• Family education: We can help prepare families to support the guest’s recovery, including understanding potential complications and how to avoid them.

Ensuring Rehabilitation Guests and Families Have Access to Resources and Emotional Support During a Difficult Time

In addition to physical healing, Ciena Healthcare recognizes the importance of addressing the emotional, financial, legal, and social challenges rehabilitation guests and families may face during recovery from a healthcare crisis. Our licensed social workers are dedicated to helping guests and families access community and financial resources that they are eligible to receive, understand and navigate healthcare decisions, grapple with the legal implications of their situation, and much more.

Key services provided by our social workers include:

• Counseling services: Providing emotional support for guests and families dealing with the stress of illness, surgery, or the transition to long-term care.
• Community resources: Connecting guests and their families with resources such as financial assistance, home care services, or support groups.
• Legal assistance: Assisting with legal complications, like powers of attorney, ensuring guest and family legal rights are protected, and navigating insurance challenges.
• Financial assistance: Social workers can help guests and families determine if they qualify for financial aid programs and help them maximize their current insurance benefits.
• End-of-life planning: Supporting families through palliative care, hospice transitions, and advance care planning when necessary.

Benefits of Coordinated Care Services

• Improved resident outcomes: Coordinated care ensures that all aspects of a guest’s recovery are addressed, improving long-term outcomes.
• Reduced hospital readmissions: Effective discharge planning reduces the likelihood of complications and hospital readmissions.
• Emotional support: Social work services reduce stress and anxiety while also helping families avoid common legal complications or financial pitfalls related to recovery.
• Resource navigation: Families gain access to resources that ease the financial and logistical burdens of long-term care or post-hospital recovery.

Our discharge planners provide:

• Personalized care plans: A detailed plan outlining the care a guest will require at home or in another care setting, including medications, follow-up appointments, and therapy.
• Home care arrangements: Assistance in organizing home healthcare services or outpatient therapy sessions to ensure guests continue making consistent progress in their recovery after leaving our community.
• Equipment and medication management: Our planners help families secure the necessary medical equipment and supplies, as well as provide guidance on medication management.
• Family education: We can help prepare families to support the guest’s recovery, including understanding potential complications and how to avoid them.