Your Discharge Planning Team

As a Jefferson Health New Jersey patient, you'll be assigned both a case manager and a social worker, although you may not require both or either of their services. These professionals will help facilitate your care while you're in the hospital, as well as coordinate your discharge plan to get you back to the life you love and ensure you continue to receive the care you need once you have left our hospital.

Discharge Planning

What's Involved in the Discharge Planning Process?

Your case manager and/or social worker will work with you, your family and the entire health care team to assess your medical, social and emotional needs and determine if you would benefit from ongoing treatment or other services either at home or at a rehabilitation facility. Ultimately, it's your physician who will decide when you should be discharged from the hospital.

How Does Insurance Work?

Your case manager will also work on your behalf to coordinate your health insurance benefits and obtain approval for both your hospital stay and any needs you may have after your hospital discharge.

What If I Have No Insurance?

If you have no insurance, a social worker will be assigned. It's important that we know your insurance situation as soon as possible so we can assign the proper professionals to your team.

What are the Different Types of Continuing Care?

If it's determined that you need continuing care after your hospital stay, you may be recommended for several different types depending on your age, activity levels, and condition of your health. These may include in-home care, short-term rehabilitation, long-term nursing care or assisted living.

Home Care

If it's decided that you would benefit from and are eligible for short-term care in your home, your case manager will help by making referrals to home care coordinators. The home care coordinator will assist with any equipment you may need. To receive home care you must be home bound, (cannot leave the house), require skilled nursing, and have home care ordered by your doctor. Home care visits are generally 1-3 per week.

Rehabilitation (Short-Term)

If you meet certain insurance standards that include a continuing medical need that only a nurse can provide, and your insurance covers this type of care, your social worker will work with you and your family to help move you to a short-term rehabilitation facility after your hospital stay.

Long-Term Care (Nursing Home)

If it's determined that it may be a safety concern for you to live in your current home, your social worker will work with you and your family to find a long-term health care facility that can accommodate your needs.

Assisted Living

If you don't require round-the-clock medical care, but would benefit from some assistance with daily activities such as bathing, dressing, medical management and more, your social worker can provide a list of available facilities. Keep in mind, this type of care is generally NOT covered by insurance. This list is also included in the patient guide you received at admission.

Community Resources

Your social worker may recommend some community resources to meet your needs. Please remember that your case manager and social worker will try to make the best possible recommendations when you are discharged; however, we must work within your doctor’s orders and insurance coverage parameters. You may always ask your nurse for your case manager or social workers, or call the main office at 856-346-7850.