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Melanie Cole (Host): If you have selected Palmdale Regional Medical Center to provide your medical care, know that employees at Palmdale Regional Medical Center are committed to service excellence. Case Management Services can help patients and their families cope with the problems and stress that can often accompany illness or hospitalization. My guest today, is Maryanne Leiby. She’s the Case Management Director at Palmdale Regional Medical Center. Welcome to the show, Maryanne. Tell us a little bit about what Case Management Services even mean to a patient and their families.

Maryanne Leiby (Guest): Okay, Melanie. The Case Management Services provides support and guidelines to help deal with an illness and its treatment, as well as to help make decisions about the discharge plans when the patient is ready to go home. We have Registered Nurses, and we have LIBNs and social workers. They’re experienced in working with the community agencies that provide services such as home health, or medical equipment that a patient may need when they go home. We also help with placement if they need to go to a facility for continued rehab services or care before they go home, like transitional care. We also evaluate if a patient is interested in Hospice or Palliative Care when they go home. We’re able to help them with those choices.

We have a Social Worker assigned to each patient care area, and they’re trained to help specifically the patient, and the family members deal with any problems or issues they may have – be it emotional, financial, social, et cetera – that can occur during an illness or hospitalization.

Melanie: As families are getting ready to take their loved-ones home, and maybe they have a catheter, or maybe they have to be on medication or – there’s a whole host of things that might be going on that they have to think about at home. How to you help them organize everything that they might need?

Maryanne: We work with the nurses as a team – and also pharmacy for the medications – but we go over with the family member or the patient -- whoever’s assisting with the care – to make sure that medications are covered either by their insurance or try to help facilitate financial workings -- if a patient doesn’t have insurance, how to get insurance, how to get care. We have community clinic connections that help with medication and that kind of thing. And also, with home health, we arrange it through the patient’s insurance – or if they don’t have insurance as well, we look into how we can get those services for the patient.

The patient never leaves without what they need at home. We make sure everything they need is ready to go – if they need oxygen, if they need medication, if they need catheter care, if they need wound care – we set that up for them. We also will help assist with a follow-up appointment either with their primary care physician or at one of the clinics that they need to start a process of getting hooked up with a physician. Frequently patients come to the hospital, and they don’t have a physician, so that’s something we work forward – with them, so they have someone to follow-up with.

Melanie: And you mentioned even some emotional issues and social workers, so what do the social workers do for families? Because sometimes it can be very difficult to have a loved-one in the hospital and even then, to take them home and have to care for them. How do social workers help the families and the patients?

Maryanne: The social workers discuss with them to find out what their needs are, and if they need support when they go home they connect them with different support services in their area that they live in. If they need care support, if they need caretakers – they’ll give them the list of caretakers they can call for support. Sometimes insurance covers home nursing visits and sometimes they don’t. We have lists for everything to provide for them – or psychiatric issues. We have patients who come in with addiction issues, so we try to provide that as well. We have different support services in the area – everyone says down the hill – there are some places we hook people up with if they need to go into a resource center after they leave the hospital.

Melanie: How do people know how to get in touch with you? Do Case Management Services show up at their room while someone is in a hospital or do the Social Workers? There’s other people involved and so how – do they just show up in someone’s room or do we have to ask for them?

Maryanne: It happens both ways. Doctors order it sometimes – they ask us for a Social Work consult. We try to see every patient in the hospital if we can, and we have rounds daily to find out what patients’ needs are. We meet with the Charge Nurses. We meet with the Doctors. The House Supervisors we meet with daily in a bed huddle. We try to keep track of what patients need. If there are social issues, they know to call us. Also on the website for Palmdale Regional, there’s a phone number they can call and ask to speak with social services. We give the patients our card – both the nurses give their cards out as well as social work – so if the patient goes home and they have an issue, they can call and reach out to us for assistance.

Melanie: And what about education, Maryanne? How do you work with the patients so that they understand -- whether it’s home health, or how to use the Oxygen or any of these other things that are – how to take care of their loved one. Are there educational opportunities to be teaching and working with these families, so they know what do to?

Maryanne: Absolutely, we provide education along with the nurses on the floor. Every patient before they go home they get a green folder. In the green folder is any type of education they would need, whether it’s regarding services they’re going to have when they go home such as the Oxygen, or a nebulizer if they’re having breathing issues, medications they go over, or just information about their diagnosis. If it’s a new diagnosis for them – or even if it’s an old diagnosis, the nurses will put in their education explaining diet and care after the hospital, when to see their doctor, that kind of thing.

Melanie: Wrap it up for us. Tell us about your team at Palmdale Regional Medical Center, and what you would like patients that are coming to the hospital – what you’d like them to know about the care that a case management worker and the services – and social work – can provide for them.

Maryanne: We have a great team. We have nurses on every floor. We try to keep the same nurse there through the say, so the patient gets to know them. They know who to call if they have any issues. They have the phone number, they can reach out to the nurse that day, or after they go home. There’s a nurse specific to every floor as well as a social worker. They work as a team to help the patient get everything that they need on discharge and they can always follow-up with us. We have a great team of nurses and social workers, and they’re very available. We do get a lot of calls when the patient goes home – sometimes just to say, “Hello,” and let us know how they’re doing because they develop that rapport with us while they’re in the hospital.

Melanie: Thank you, so much, for being with us today, Maryanne. It’s really important information for listeners to hear. You’re listening to Palmdale Regional Radio with Palmdale Regional Medical Center. For more information, you can go to PalmdaleRegional.com, that’s PalmdaleRegional.com. Physicians are independent practitioners who are not employees or agents of Palmdale Regional Medical Center. The hospital shall not be liable for actions or treatments provided by physicians. This is Melanie Cole. Thanks, so much for listening.