Search

Navigating care through the hospital system can be a daunting task for any patient. When faced with a difficult diagnosis or a complex healthcare journey, patients hope for, and deserve, the gold standard of support in helping them get connected with the resources, counseling, follow-up care and action plan to Fight the Good Fight.  That hope quickly turns into reality and relief when the case managers and social workers at Renown Health step in to help.  Renown’s Hospital Care Management department consists of caring, compassionate case managers and social workers who are the ultimate welfare protectors. By tapping into the needs of every patient and bridging any needs gaps with the resources they need, these team members move mountains to ensure every case results in the best possible outcomes.  Your In-House Patient & Family Liaisons  Whether they are providing therapeutic services to patients experiencing behavioral health issues, referring patients in addiction recovery to resources to aid in their recovery process or guiding a patient with cancer through the complicated care process, our case managers and social workers ensure patients and family members stay on course throughout their healthcare journey from beginning to end.  “Our department has teams that cover all areas of the hospital, including the emergency department,” said Mary Matteoni, LSW, Director of Hospital Care Management at Renown Health. “We see all-aged patients, ranging from NICU babies and families to those experiencing the last moments of their life (and everyone in between).”  “All of our cases start in the prevention, or pre-acute, phase and continue through the healthcare continuum,” added Alma Yanez, DNP, Manager of Hospital Care Management at Renown Health. “We are here to partner with patients and families, helping them assess, plan, implement and evaluate options of care and services to meet everyone’s needs.”  These team members are your go-to counselors, crisis interventionists, community resource referrers, and most of all, patient advocates. When patients need a leader to follow if confronted with an intimidating hospital stay or life-altering diagnosis, our experienced Hospital Care Management department gladly steps in to be that support system, easing fears and anxieties along the way. Providing optimal care and guidance is par for the course for this team.  "We help patients understand confusing diagnoses, arrange rehab and other post-hospital supports, help families understand how they can best support a loved one facing a ‘new normal’, navigate end-of-life decisions and so much more,” said Abbie Smith, LSW, MSW, Social Work Care Coordinator at Renown Health.     This department also serves as Renown’s discharge experts. Our case managers and social workers facilitate appropriate length-of-stay and work around the clock to arrange services for patients as they acclimate back home.  “Reviewing each patient’s medical records to ensure every resource and section of care is delivered at the right time is crucial,” said Alma Yanez. “Patients depend on us to use the best judgment when it comes to cost-effective outcomes and the planning and execution of their care after they leave our hospital.”  Expert care coordination, health resource referrals, therapeutic services, workshop facilitation, healthcare financial liaising, crisis support, staff training...a better question for this department might be, “what don’t they do?” These team members are proud “do-it-all-ers.”  “Our team is proudest of being a support to our patients and their families, as well as the positive impact our work has during traumatic and difficult times in people’s lives,” said Abbie Smith.  “Everything is ‘Figure Out-able'”  Those are the wise words said by Abbie Smith, LSW, MSW and emphasized by her entire team. No case is too complex for our Hospital Care Management department, yet every case poses great rewards for both the providers and the patients.  “I love being a social worker for Renown, as every day is filled with new and diverse situations,” said Abbie Smith. “As the social worker assigned to the trauma intensive care unit, my experiences at Renown are challenging but very rewarding. I have the privilege of helping victims of traumatic situations get the social, emotional, psychological and medical assistance they need to help recover from their experience.”   Every team member in the Hospital Care Management department leads with the utmost care and concern for every single patient and their families, leveraging compassionate communication techniques every step of the way.  “For so many patients, they are admitted to the hospital and receive life-changing news,” said Mary Matteoni, LSW. “Our department is the one to answer questions like ‘what do I do now?’ or ‘how am I going to get through this?’ Our team members are experts in their field, and they have a unique holistic lens into the patient’s situation. They spend time learning about the patient’s experiences and circumstances before they were admitted and navigate the next steps of what their new reality means. We spend countless hours ensuring each patient has the resources needed to be successful upon discharge.”  “I always ask open-ended questions to help reduce my patients’ fears, such as, ‘How are you feeling?’ or ‘What can I do?’” added Abbie Smith. “We listen to learn more about the individual’s unique circumstances so we can offer appropriate support and guidance.”  Compassionate communication is especially important when our case managers and social workers approach terminal illness, palliative care options and end-of-life conversations with patients and families. While never easy, these team members always lead with empathy.  “End-of-life conversations, which I help facilitate, frequently occur in the ICU,” said Abbie Smith. “When needed, I help families work through painful, initial moments of grief after losing a loved one.”   Each social worker and case manager takes any opportunity to lessen patient stress, which can make all the difference in the end.  “Patients and families look to us for comfort and support, and we are proud to be a source of solace for them,” said Kami Price, LSW, Supervisor of Social Services at Renown Health. “No matter how complicated the case is, we are always there to guide them through what may otherwise be a daunting journey.”  Now Hiring: Holiday Heroes Needed  This dynamic department is expanding! This team is seeking case managers and social workers in a wide variety of disciplines, including behavioral health, oncology and chronic care management. From social work bachelor’s and master’s students looking for an enriching entry-level opportunity to highly experienced case managers seeking to make a genuine difference, the Hospital Care Management department is the team for you.  “Our team consists of some of those kindhearted and thoughtful individuals I’ve ever worked with,” said Alma Yanez, DNP. “Those attributes are vital to ensuring a positive patient experience, especially as we help them navigate a complicated and intimidating healthcare journey.”  “Respect and compassion are also required characteristics to work in social services,” added Abbie Smith, LSW, MSW. “Having respect for our patients, their personal information and challenges is essential. Social workers interact with highly diverse populations, and it is imperative to keep an open mind and seek understanding of patients’ unique situations.”  The holiday season can be especially difficult for many patients and families dealing with a difficult diagnosis or facing a long hospital stay. That’s why we need social work and case management heroes more than ever this time of year. Giving a patient and family the gift of support can be one of the greatest gifts of all.  “I strongly believe that Case Management/Social Services often gets to be the light in many dark moments,” said Mary Matteoni, LSW. “I have a great passion for the work that is done in Hospital Care Management and am so proud of the team we have built and the work they do daily. We are a team of laughter, enjoyment and solid expertise in our work.”  It’s time to ask yourself: are you ready to change the lives of patients and families?

Read More About Department Spotlight: Hospital Care Management

When thinking about taking care of your total health, what comes to mind? Perhaps participating in your annual check-ups, taking your prescribed medication, eating a nutritious diet, checking in with your mental health, the list goes on and on.   Now, put yourselves in the shoes of someone who may not know where their next meal may come from, someone who may be homebound and not have access to transportation, someone who may be on a fixed income, someone facing homelessness or even someone who may be struggling with substance abuse issues. Getting healthy – and staying healthy – comes with a unique set of obstacles, or social determinants of health, for these patients to overcome. Inequities around social determinants and health behaviors have an outsized impact on patient outcomes, and social and economic factors make up 40 percent of those inequities.  This is where the caring and compassionate community health workers, social workers and registered nurses that make up Renown’s Community Care Management (CCM) department rise to the occasion. As the need for resources grows in northern Nevada, these dedicated team members fill those gaps and ensure every patient feels prepared, educated and equipped with everything they need to continue their care journey and live a healthy, fulfilling life.  Defying Disparities  When our community at risk faces healthcare disparities, it can create complications in each patient’s life that may keep them from addressing their healthcare needs and affect the likelihood of them being admitted or readmitted to the hospital or continuing to struggle with their care management – but not on CCM’s watch. Whenever possible, the CCM team steps in to provide critical resources, education and care journey guidance for any patient that finds themselves in need.  “In the simplest terms, we do outpatient case management with vulnerable populations,” said Barb Mader-Scherrer, Director of Community Care Management. “It may be anyone from elderly people who need help managing chronic diseases, to patients experiencing homelessness who are being discharged from the hospital. We work with folks who are facing all sorts of challenges.”  Several roles make up the CCM department, including Community Health Workers. These team members are the resource experts, on the front lines of helping educate patients and supporting them as they navigate through the facets of their care. Their main goals? Avoid admissions and readmissions to the hospital and continue to meet their unique goals.  “I have the pleasure of working with patients who may need financial help, transportation help or even help utilizing the food pantries in our community," added Steve Arm, Community Health Worker. “We help patients navigate healthcare and social services, address social determinants of health, encourage self-efficiency and provide general health education for many chronic conditions. We also provide home visits for our patients who need extra support.”  “The day in the life of a Transitional Community Health Worker is to outreach to the patient while being admitted, do a bedside assessment, complete the social determinants of health evaluation and provide any resources needed to avoid readmission,” added Sherrie Skaggs, Community Health Worker. “Our main population is Medicaid, and many are homeless and financially challenged. As needed, we continue to ensure that follow-up is completed, and all needs and goals are met.”  For those learning to cope with their condition and needing hands-on help especially after discharge, the CCM Social Work Care Coordinators take on this complex aspect of the healthcare journey. These individuals provide support and intervention for Renown patients facing a chronic, behavioral health or substance dependency condition to improve their overall quality of life beyond hospital walls, developing a strong framework to build a long-term healthcare plan.   “As social work care coordinators, we help connect patients with mental health resources, welfare programs, community support, caregiver burnout resources, placement for loved ones with terminal illnesses and much more,” said Irina Osmolovska, Social Work Care Coordinator. “Requests that come to us run the gamut of homelessness, family crisis, food insecurity and even situations where a patient has no electricity for their life-saving medical equipment. We receive challenging requests and are always ready to go above and beyond to advocate for our patients.”  Possessing a profound understanding of the delicate balance between medicine and the patient spirit, the CCM RNs help bridge the gaps between the hospital or primary care practice and post-discharge settings, ensuring a smooth transition for patients as they move from one healthcare setting to another. With their expertise in care coordination and patient education, these RNs help enhance patient outcomes and promote continuity of care.  “Our group is responsible for making discharge follow-up calls to patients who have Medicare, as well as scheduling their hospital follow-up visit if needed,” said Vanessa Alford, Consulting RN. “The goal is to have every patient see their primary care physician within 14 days of discharge for continuity of care and to prevent readmissions. We also screen patients for eligibility for Chronic Care Management or Personal Care Management. In addition to setting up the patient for follow up, I review each patient's medications, answer any questions they may have about their medications and health conditions.”  As another important part of unpacking the intricate web of social determinants impacting health, CCM RN Care Coordinators have the extraordinary opportunity to extend this department’s compassionate care beyond the boundaries of the traditional in-office environment. Whether it be through virtual connections, heartfelt conversations over the phone or in-person encounters outside the hospital, RN Care Coordinators create holistic and enduring plans of care for individuals facing chronic challenges – including behavioral health issues and chemical dependency struggles – at every stage of life.  All in all, the CCM department recognizes the interconnectedness of physical, emotional and social well-being for all patients, fostering a sense of wholeness and empowerment to ensure they continue to meet their goals and live healthier, happier lifestyles.  “Our team has a holistic approach to our work,” said Barb Mader-Scherrer. “We look at the whole picture. What are the medical things we can do for this person? What education do they need to help them manage their condition? Do they have food in their house? Do they have a safe living environment? Are there substance abuse issues? Do they need help in managing their medications?”  “My 18 years of experience in various areas of hospital nursing and home health have given me the knowledge to serve patients in our community holistically, and I feel good about what I do,” added Vanessa Alford. “I hope that I am able to lessen the load on the medical assistants and providers in the clinics so they can focus on their patients on site.”

Read More About Department Spotlight Community Care Management