Our purpose is to provide overall coordination of care, facilitate communication, and ensure continuity of care through assigned personnel known as facility
case managers.
We have a diversified health care team to provide specialized care for patients of all ages, newborn to adult.
- Improve overall outcomes through collaboration
with facility staff and through coordination of care.
- Educate patients and staff in order to contribute
to positive outcomes through increased knowledge
of disease process and treatment.
- Serve as a bridge between patient, physician,
facility, and home health.
- Provide multidisciplinary care in order to assist
the patient in reaching his or her full potential.
- Continually work to improve the quality of life
for the aging population.
- Assign a case manager to provide overall patient
care and coordination of services.
- Complete physical, psychological and social
assessments (OASIS) on each patient.
- Develop comprehensive plans of care for
each patient.
- Work with an interdisciplinary team to provide
oversight and collaboration in patient care.
- Participate in multidisciplinary care conferences
in order to establish patient care plans.
- Assess residents to determine whether they
are eligible to participate in established disease
state management programs, including
Telehealth monitoring.
The facility case manager will have overall
responsibility for the facility he or she is assigned to.
Responsibilities include, but are not limited to:
- admissions
- direct patient care
- coordination of care
- communication
- patient education
- care conferences
All patients must meet the following conditions
of participation in order to qualify for admission to
the home health program. The criteria include, but
are not limited to, the following:
- must be homebound (if payor requirement)
- require a physician order for home
health services
- require skilled intermittent care
- need a responsible caretaker
For additional information, e-mail
info@upmcjeffersonhomehealth.com.
