Who We Are
Healthcare has seen many changes over the last few years, including the move to improve care coordination and help patients transition successfully after their hospital stay and back to their homes or onto their next level of care post-discharge. At Vanderbilt University Medical Center, our patients and their families come first!
Transition Management is comprised of RN case managers, social workers, and discharge planners and is supported by our leadership team and other support staff. Our case managers and clinical social workers utilize advanced skills to assess and coordinate care for diverse patient populations. They collaborate and consult with a multi-disciplinary team of skilled and specialized healthcare professionals, as well as with patients and their families, to ensure safe and effective coordination of care.
What We Do
Effective care coordination helps to advance the care plan during the inpatient stay and to transition patients to the most appropriate setting. The goal is to ensure a safe, transition to the appropriate level of care, whether it is home with home care or to a facility. Patients have choices in selecting a provider that will meet their needs after discharge. Our staff are experts in assisting the patient, family, and team to identify appropriate are settings for the patient.
Our staff anticipate the various medical needs of the patient, assess the patient financial resources and family support to ensure the family is on board and in agreement with the plan of care, and utilize the multidisciplinary team to address all the patients’ needs. In the inpatient setting, care coordination utilizes the nursing and social work assessment processes to assess, implement, reassess and risk stratify for patients — in collaboration with the multidisciplinary team. Our nurses and social workers, in collaboration with our support staff and team, truly impact patient outcomes and the trajectory of their clinical needs going forward.