The Coordinated Care Resource Center supports the Coordinated Care department by reallocating time-consuming case management and discharge planning functions to a central support area. RC staff will arrange post acute referrals/resources and provide clinical updates to payers to obtain authorization for length of stay and appropriate level of care. In addition, the Resource Center provides administrative/secretarial support and performs data/outcomes analysis. Roles include payer specialist, referral specialist, technical support specialist, data analyst and clerical support.
Standards for Referral Tasks
- All requests should be sent through Heath link In-Basket, even if a phone call has been directly made to the Resource Center. **If requesting Late day or same day transportation or cancellations a text paged or phone call is needed, in addition to being tasked via Health Link In Basket.
- When tasking in Health Link, all staff use a formal documentation style as you would in the patient’s chart. Each task should state what is expected, date and time frame for completing when appropriate – for example:
- Verify benefits and/or verify preferred providers
- Which facility or agencies to send referral to. Maximum request at a time to send 3-4.
- Whether to include fax attached or print attached documents
- Transportation: Type/mode, date and time preferred, to where.
- DME needs are to be notes in the “Notes to Provider” field in ECIN or indicate the equipment by using the check boxes if appropriate. Limit SNF options to 3-4 per task – unless you make a special request to widen the search.
- The RC will document information in a Progress Note in Heath link as well as respond via In-Basket, that a note has been made. If the In-Basket request is more of a conversation for example, an ECIN referral needs to be resent for any reason, a Progress note will not be made in HL. The note back in the In-basket will indicate, “No Progress note written in HL chart”.
- The RC will assume the patient is discharging to their home address as listed in Health Link, unless informed otherwise.
- The RC will add a note in the “Referral Comments” area of ECIN, directing the agency to contact the task-sender with questions, or with delivery details for DME referrals.
- All medication related prior authorization requests should be directed to the unit pharmacist or Chartwell.
- Transportation set-up information (day, time, mode, vendor) will be documented in the Discharge Plan.
- The RC will page the task-sender if the task cannot be completed within 2 hours.