Patient Resource Services Transitions of Care (Discharge Planning, Logistics, and Education) The Department of Patient Care Services (Patient Logistics, Clinical Outcome Nurse, Care Coordination and Social Services) has been structured to ensure that patients receive timely, high-quality, patient-centered care and attention throughout their stay at St. Elizabeth. Our team consists of Patient Logistics Coordinator Nurses, Senior Admission Specialists, Clinical Outcomes, Care Coordinators, Utilization Management Nurses and Social Workers. All of whom provide assistance and support along our care continuum, from admission to discharge. It is through teamwork at every level that we can achieve excellence in care. We understand that illness affects everyone in the family, not just the patient. That’s why our supportive and compassionate team are always here for you. Clinical Outcomes Department Clinical Outcomes RN act as clinical resource, change agents, research mentor, educator, and consultant to assist in planning, implementing, and coordinating care for select patient populations across the continuum of care. Our team focuses on patients with chronic progressive disease and other select diagnosis related to higher chance of readmission. Provide comprehensive education to patients/families on specific disease management. Assist to help understand health condition and developing self-care skills to better manage health after hospitalization. Collaborate with patient/family and healthcare team to achieve optimal outcomes, improved wellness and decrease chance of readmission. Care Coordination Department Discharge planning begins the day that a patient is admitted to the hospital and will continue throughout their stay. Our Care Coordination team is here to assist patients, and their families with their discharge planning need to ensure a smooth transition back home. The Care Coordination team consists of registered nurses and social workers who are available from 8:00 a.m. - 4:30 p.m. every day. Our services include discharge planning assessments, setting up home health, rehabilitation, medical equipment, and referrals for community resources if appropriate. Our goal is to provide you with timely, personalized discharge planning services to ensure you have a safe discharge plan that meets your needs once you are medically ready to leave the hospital. Social Services Department While there are care coordinators and social workers assigned to the inpatient units, we also have a dedicated social service team in the specialty areas of Maternal Child, Outpatient Cancer Care, and the Emergency Department. Our services in these areas include assessments, crisis intervention, resource identification, patient/family education, and referrals for community resources. Our goal is to provide you with timely personalized assistance with your psychosocial needs. Patient Logistics Department At St. Elizabeth Healthcare, we simplify the process for making patient transfers. The Patient Logistics Center is a single system solution for all St. Elizabeth Healthcare facilities to simplify patient placement needs. This centralized bed placement area follows best practice standards and serves as a true "hub" for all patient flow activities throughout the system allowing us to quickly and efficiently move patients through the healthcare journey. Just call one number anytime, 24 hours a day, seven days a week. This one-call solution is designed to simplify the transfer and admission process, ensure continuity of quality care, and expedite access to critical services for your patients. The associates of St. Elizabeth Healthcare’s Patient Logistics Center can assist with transfers from Acute Care facilities, Skilled Nursing facilities or direct admissions from physician offices. The Patient Logistics Center Nursing staff uses critical thinking skills to facilitate rapid transfers of patients from other facilities requiring a higher level of care and arrange ground and air transportation needs. This ensures patients are given the best opportunity for better outcomes. Our goal is to achieve efficiencies in precise patient placement by expediting placement from all admission areas. Information Needed to Expedite the Transfer of Your Patients Your call will be answered by a logistics coordinator, who is trained and experienced in Critical and Acute Care environments and uses critical thinking skills. He or she will: Determine the appropriate destination for the patient Identify and contact an accepting physician Reserve a bed Arrange transportation ground or air needs When you call, please have the following information available: Your name and contact information Referring physician or hospital’s name and contact information Patient’s name, age and date of birth Clinical status, diagnosis and supporting clinical information Preferred unit Specialty care or service required The use of our advanced technology and streamlined approach for process and communication will eliminate workflow redundancy and provide a visualization of real time data. We want you to have One call, that's all! Contact Us Clinical Outcome Nurses (859) 301-5413 Hours of Operation: 8 a.m. to 4:30 p.m. Monday through Friday Care Coordination/Social Services (859) 301-2275 Hours of Operation: 8 a.m. to 4:30 p.m. Monday through Friday Patient Logistics Center (859) 301-2382 Hours of Operation: 24 hours per day 7 days per week Resources Click here to download a printable PDF of the St. Elizabeth Healthcare Patient Toolkit. Click here to download the Nursing Home Placement Handbook. Education Click here to download a printable PDF of Commonly Used Inhalers. Click here to download a printable Respiratory Medication Inhaler brochure. Click here to download a printable PDF of the St. Elizabeth Healthcare COPD Stoplight Card. Click here to download Heart Disease, A guide for patients booklet from the St. Elizabeth Healthcare Heart & Vascular Institute. Click here to download a printable Stroke Education Handbook. Click here to download our Living with Heart Failure for Patients and Families brochure.