The Case Management Department at Calais Community Hospital is comprised of a Registered Nurse Case Manager and a Licensed Social Worker who work collaboratively with patients, families, providers, and the healthcare team to ensure a safe and coordinated plan of care. Through a multidisciplinary approach, the department assesses, plans, coordinates, monitors, and evaluates each patient’s healthcare needs while promoting quality outcomes and the appropriate use of available resources.
Case Management begins discharge planning early in the patient’s hospitalization to help ensure a smooth transition to the next level of care. The team assists patients and families in identifying post-discharge needs, coordinating services, addressing barriers to discharge, and connecting patients with appropriate community resources.
Case Management services include assistance with:
- Discharge planning and transition of care needs.
- Placement coordination for skilled nursing facilities, assisted living facilities, long-term care, and other appropriate settings.
- Long-Term Care MaineCare application assistance.
- Development of individualized care plans based on the patient’s medical, functional, and psychosocial needs.
- Referrals and coordination for home health services, rehabilitation services, hospice and palliative care, durable medical equipment, and community support programs.
The Case Management Department works closely with physicians, nursing, rehabilitation services, pharmacy, dietary, and community partners to develop individualized plans that support each patient’s goals, promote independence, and ensure a safe transition to the appropriate level of care.
For more information about Case Management services, please contact the Case Management Department at (207) 454-9270