Alzheimer’s patients require careful and skilled discharge planning and post-hospitalization treatment plans. Some patients may be discharged directly to their home, while others are discharged to a rehabilitation facility.
The Alzheimer’s Care Resource Center’s geriatric care manager plays a significant role in the discharge planning and post-hospitalization treatment plan process.
As care managers, it is vital that we closely monitor the treatment plan in order to assist in identifying the appropriate discharge recommendations as well as implement them on behalf of the patient, his or her medical team members, and other formal or informal networks, including:
- physical therapy
- occupational therapy
- speech therapy
- skilled nursing
- respiratory therapy
- infusion services
- private duty and custodial care
- medication management
- durable medical equipment
The geriatric care managers at the Alzheimer’s Care Resource Center assure that the care and services the patient requires are coordinated, delivered, monitored and evaluated to meet post-hospitalization treatment plan goals.