INDEX
Care Transitions
Table of Contents:
Cross References:
About Care Transitions
The term “Care Transitions” incorporates both Social Work and Case Management services. Social Work is available on weekdays M-F 24/7 at UED and during M-F afternoon/evening hours at HED. Their services include:
Discharge planning
Cabs/bus tickets
Prescriptions
Reporting abuse or sexual assaults
There are also schedulers available to help setup follow-up appointments. They are currently available by phone at 5-2273.
Vocera Groups for Care Transition team:
As of July 31, 2023, please use the Highlands on-call list for UED patients during the hours of 11pm to 7am.
Paramedic Home Visits
“Birmingham C.A.R.E.S.” is a program developed by BF&R in coordination with UAB social work and care transitions to perform home visits by a group of paramedics to decrease ED visits.
They check vitals, review medications, help with follow-up appointments/scheduling.
Contact ED social worker to potentially enroll a patient.
Inclusion Criteria for Patients:
Consistent address inside the city limits (ie. not homeless)
Consistent medical chief complaint (eg. COPD, not psych)
Social Admits
If you have a "social" admit without a medical/psych reason for admission:
Contact social work and ask if the patient might qualify for the social admit program to nursing home/boarding home.
Contact a member of the ED admin team so we can track the case and monitor LOS and final disposition.
We are not expected to write admission H&Ps or nursing home prescriptions.
KEYWORDS: SW, social work, Birmingham cares, social admits, social