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Care Management

Care Management

As a vital piece of the Maricopa Integrated Health System team, our goal is to enhance the health and wellness of the community we serve. As social workers, case management and care coordinators, we assist patients and their loved ones in crisis intervention, problem solving, discharge planning and coordinating community resources.

MIHS Care Management is made up of three different departments committed to providing the highest level of care to each of our patient’s individual needs. These three departments include: Care Management, Ambulatory Care Coordinator and Psychiatric Care Management.

Care Management Department at MIHS

The Care Management Department at MIHS is comprised of social workers and RN care managers working cooperatively to ensure that care is provided to patients in a seamless and cost effective manner.  As a vital part of the Maricopa Integrated Health System team, our goal is to enhance the health and wellness of the community we serve.  As social workers and nurse care managers, we assist patients and their loved ones in crisis intervention, problem solving, discharge planning and coordinating community resources.

Specifically, the care management teams are responsible for assessing appropriate utilization of resources and patient flow, delivering social services, and coordinating transitions of care.

Appointments and Referrals

  • To request care management intervention, patients can request to speak to a care manager at any time.  A physician or nurse may also consult a care manager for specific needs.
  • Care Managers can be located in a central space on each unit.  They can be reached by phone or text pager.
  • In the inpatient setting, Care Management staff is organized into five teams assigned to clinical units, seven days a week.  The Emergency Department is staffed with a social worker seven days a week for a minimum of 16 hours per day.

Treatment and Services

  • Discharge Planning
    • This begins on day one of admission.  The care managers coordinate with the medical team to plan for your needs and preferences for a safe transition from the hospital.
  • Community resources
    • Social workers provide community resource referrals for a variety of needs, including health coverage information, food assistance, transportation concerns and advanced directives.
  • Coordinating post- hospital care
    • Care managers coordinate ongoing medical needs, such as: Skilled Nursing Facility, Home Healthcare and Durable Medical Equipment.
  • Supportive listening and Crisis intervention
    • Care managers provide support services during trauma, death and for psychiatric needs.
    • They also provide referrals to support groups or counseling.
  • All services are provided by licensed master’s prepared social workers and licensed nurses with case management certification.

Patient Education

  • Relevant tips/useful information
    • Patients have a right to request an individualized discharge plan be developed for them.
    • Maricopa Integrated Health System utilizes Silvervue tablet technology to provide interactive choice and quality data for patients about post-hospital services.

Ambulatory Care Coordinators

The Ambulatory Care Coordination is comprised of RNs and patient service specialists working collaboratively with clinic providers, staff, patients, family members, health plan representatives and hospital transitional team members to address the health needs of those in our care and in our community.

Care coordinators identify patients that are high risk and may have multiple conditions that can lead to future high cost patients or readmissions. The Care Coordinators act as a resource to the clinic staff in implementing the National Committee for Quality Assurance (NCQA) in the Patient Centered Medical Home model.

Care Coordinators are located at the Family Health Centers, Monday through Friday during usual clinic hours.

Treatment and Services

  • We work collaboratively with the provider, staff and patient to evaluate the quality of the patients health and provide:
    • Chronic disease management
    • Pre-visit planning

MIHS supports the Patient Centered Medical Home model by anticipating, monitoring and addressing population health needs across the continuum of healthcare. Coming soon.

Psychiatric Care Management

The Psychiatry Care Management Department at MIHS consists of social workers who work with, and care for patients admitted with both respect and compassion. Our social workers work in interdisciplinary teams to treat and to provide resources for patients and their loved ones. They coordinate the court ordered evaluation process all patients must complete, and provide education and support through this process. We have a variety of services available to help families cope and work closely with them to provide counseling and support. Social workers find appropriate discharge plans and services for all patients with resources that are available.

Appointments and Referrals

  • Each patient is assigned a social worker. In order to reach their assigned social worker, patients can call 480-344-2000.
  • Patients can also ask their nurse to contact their social worker Monday through Friday, from 8 a.m. to 4 p.m.

Treatment and Services

  • MIHS is the largest provider of inpatient behavioral health services in Arizona, and offers the only facilities in Maricopa County that conduct inpatient court-ordered mental health evaluations.
  • Our Desert Vista Behavioral Health Center in Mesa and Behavioral Health Annex on the main MIHS campus treat a high volume of patients with complex behavioral health needs. All patients are cared for with respect and compassion by masters prepared social workers or counselors.
    • Social workers complete a psychosocial assessment on all assigned patients to determine characteristics such as the patient’s strengths and challenges.
    • Discharge planning is started at the time of admission and includes input from patients, families and outpatient teams.
    • Supportive counseling is provided to patients and families to help them cope and better understand mental illness.
    • Social workers coordinate with the court system and the Regional Behavioral Health Authority (RBHA) to get the best outcome for patients within the mental health court system.
    • If a patient has an assigned outpatient team, the social worker coordinates with the team throughout the patient’s stay for continuity of care.
    • Social workers/counselors provide individual and group counseling on subjects such as substance abuse, coping skills and solution focused processes.

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