Preadmission/Admission Assessment
(prospective and referral-based)
- Risk Assessment
- clinical appropriateness
- projected LOS
- financial clearance/risk for COB/free care eligibility
- psychosocial risk (abuse, guardianship, advance directives)
- projected discharge needs
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
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
Discharge
- Communications with patient/family, team, community, payer/PCP/outpatient care coordinator
Documentation
- Patient Assessment
- Progress Notes
- Clinical Pathways
- Referrals
Utilization Management
- MCAP (Managed Care Appropriateness Protocol)
- Clinical denial management
- Utilization Review
Post-acute Calls to Patients
Care Improvement Initiatives
