While recovering from a surgery or illness in the hospital, there are a lot of things to think about, from scheduling follow-up appointments, finding a physical therapist, sorting through bills or even getting a ride home. That’s where the care management team can help.

This team of registered nurses and licensed social workers helps patients through their hospital stay and after, ensuring patients have the best outcome possible.

“The stress level of a patient can increase in the hospital setting,” said Wanda Ashbaugh, supervisor of care management at UCHealth Yampa Valley Medical Center. “We attempt to reduce that stress and assist with the best outcome for the patient and their family.”

The care management team works collaboratively with physicians and other teams, such as physical therapy, occupational therapy, laboratory services, the pharmacy and community organizations, all to help make sure a patients’ needs are met.

“We work across the whole continuum of care,” Ashbaugh said. “We assess, plan, coordinate and evaluate options and services that we feel are supportive to the individual’s health.”

For instance, if a patient needs a short-term stay at a nursing home facility after a surgery, the care management team can set up that stay.

Or, if a patient is visiting from out of town and needs help getting to and from the airport, sending medical equipment to their house and setting up appointments with physical therapists in their hometown, care management can help with that.

“We can help set up services locally as well as for people visiting from out of town. We want patients to be able to go back to their home communities as safely as possible,” Ashbaugh said. “Some patients may have complex care situations: If someone visiting from Georgia falls and breaks their hip on the mountain, we can help set up durable medical equipment, home health, coordinate getting them home and link them to their providers in their home community.”

Care management also helps with psychosocial health, behavioral health and mental health support for patients, and assists patients who have been through a trauma, such as a car accident.

“Often in the emergency department, patients come in with crisis,” Ashbaugh said. “We’re here to support patients and their families. Social workers provide follow-up care and phone calls to patients based on the situation. They debrief with staff, answer questions and provide support however it is needed.”

Every patient in the hospital is visited by the care management team. Many patients in the emergency department are also seen.

When a nurse or social worker with the care management team interacts with a patient, they’ll review information in an effort to try to prompt questions.

“We ask a lot of questions to try and figure out what their needs are going to be once they leave the hospital setting,” Ashbaugh said. “Then we coordinate with the interdisciplinary team within the hospital, along with community resources, to provide a collective base of information that will assist the patient upon discharge.”

That assistance doesn’t end when a care management worker leaves the room.

“At any point, the patient can ask us to come back in and speak to them about other concerns if they think of something else,” Ashbaugh said.

The care management team doesn’t make decisions for a patient, rather the decision-making process is collaborative, with the team providing information and ideas, and the patient deciding what works best for them.

Patients shouldn’t hesitate to ask if they have a question or need, no matter how big or small it may seem. Remember, the nurses and social workers on the care management team truly do care.

“Knowing that we’re assisting patients when they’re at their most vulnerable and providing services so they can get back into their home and to their families is satisfying,” Ashbaugh said.

Susan Cunningham writes for UCHealth Yampa Valley Medical Center. She can be reached at cunninghamsbc@gmail.com.