Service Provided

1. Preadmission/Admission Assessment
     (prospective and referral-based)
      A. Risk Assessment 
             ~  clinical appropriateness
             ~  projected LOS
             ~  financial clearance/risk for COB/free care eligibility
             ~  psychosocial risk (abuse, guardianship, advance directives)
             ~  projected discharge needs

2. Oversight and Facilitation of Plan of Care
       ~  communications, team and patient/family, payer and community
       ~  clinical appropriateness, authorizations and approvals, payers and
            PCP’s
       ~  facilitating plan of care    

3. Patient Education and Staff Support
       ~  continuity and consistency of plan of care, and communications
           amongst providers and patient/family, payer and community
       ~  patient education about financial implications, levels of care and post-
           acute providers of care required to meet ongoing care needs after
           discharge
           
4. Discharge
       ~  Communications with patient/family, team, community,
            payer/PCP/outpatient care coordinator

5. Documentation
       ~  Patient Assessment
       ~  Progress Notes
       ~  Clinical Pathways
       ~  Referrals

6. Utilization Management  
       ~  MCAP (Managed Care Appropriateness Protocol)
       ~  Clinical denial management
       ~  Utilization Review

7. Post-acute Calls to Patients

8. Care Improvement Initiatives