Care Management

Who works in the Care Management Department?

Our staff consists of case coordinator nurses, registered nurses, social workers and infection control nurses. This team works together with physicians, patients and their families, staff nurses and third-party payers to provide access to the most appropriate level of care and provide quality, cost-effective care and services.

Case coordinator:

A case coordinator works with the entire health care team to coordinate case management, utilization review, infection control, pastoral care and quality and risk management.

To contact a case coordinator, call (815) 876-3301

Social worker:

A social worker can help:

• Plan for discharge to home, nursing home or another facility, including getting referrals when necessary.
• Advise you and your family of community resources available during and after a hospital stay and can make referrals for continuity of care and planning.
• Provide support to cope with the stress which may result from a difficult medical diagnosis or treatment.
• Provide you with written information and forms in Illinois Advance Directives.
• Answer any questions regarding Advance Directives and the hospital’s policy on Advance Directives.

Social services assistance may be requested by anyone – patient, family or hospital staff. For more information about social services, you can call extension 2152 from a hospital room or call (815) 876-2152. You can also ask your physician or nurse to contact the social worker for you

There is no fee for this service.

What if I Need Extra Time in the Hospital to Recover?

Sometimes after an illness or surgery, you may get to a point in your recovery where you don’t need full inpatient hospital care but are not yet ready to go home. Patients who need this intermediate level of care can use the Extend & Mend Program. This is a Medicare program designed to provide additional inpatient care to patients needing extra time to heal or strengthen before going home.

Extend & Mend allows physicians to change a patient’s level of care from “acute” to “skilled rehabilitation.” It is designed to be short-term. Even though you may be in the same bed in the hospital, you will not be an inpatient. This may also be called a swing bed program.

Often the Extend & Mend Program is used for patients who have had surgery such as hip or other joint replacements or for patients who have had a lengthy illness. A patient can also transfer from a larger hospital to the Extend & Mend Program ay OSF Saint Clare.

If a patient is already an inpatient of OSF Saint Clare, physicians can change their a level of care from “acute” to “skilled rehabilitation.” This means their hospital designation changes from inpatient to Extend & Mend patient allowing them to stay in their same room.

Under Medicare rules, patients must have at least a three-day stay as an acute patient and be admitted to the hospital for a condition that was addressed during the three-day hospital stay. Patients must need ongoing monitoring and/or require rehabilitation therapy in order to qualify for the Extend & Mend program. Once patients are in the Extend & Mend Program, they must continue to show progress toward reaching their goals.

For more information about the Extend & Mend Swing Bed Program, contact the care management department.

What if I need help with infection control?

For more information, call (815) 876-2272.

How can I learn more about inpatient services and observation services?

For more information, call (815) 876-2290.