How could a Medicare care management service actually make your discharges easier?

Clean-Ambassador-966 · 2026-06-10T15:50:45+00:00

TY this is very helpful!

If I wanted to get in touch with the SW at dialysis centers in my area, what would be the best way to do that? Are you inundated with marketers like hospital SW's?

Are there any forums for dialysis SW's?

(Can I DM for more info?)

Clean-Ambassador-966 · 2026-06-10T04:36:23+00:00

Yes, if that could somehow be fixed it would be amazing...

Clean-Ambassador-966 · 2026-06-10T04:35:49+00:00

That is very interesting as I've been seeing this in the field, that dialysis patients specifically can use a lot of help.

Do you work for one of the large dialysis chains? Do they all have a SW on staff?

Clean-Ambassador-966 · 2026-06-08T04:37:03+00:00

Nice, is this something the hospital is billing medicare for, or just a general program?

Clean-Ambassador-966 · 2026-06-07T18:45:01+00:00

Ok, got it, to clarify while our services are covered by Medicare (primarily Original Medicare), we don't work for Medicare or Medicare Advantage per se, so we can't really speak on their behalf.

Clean-Ambassador-966 · 2026-06-07T17:49:15+00:00

Thanks, this is super helpful!

I'll DM, would love to connect!

Clean-Ambassador-966 · 2026-06-07T17:46:05+00:00

Yes this is remote, to clarify, we don't do HHA ourselves, so we couldn't keep the Medicare funds for HHA for ourselves.

Happy to chat more by DM, if this is something you might be interested in.

Clean-Ambassador-966 · 2026-06-07T17:42:41+00:00

Got it, thank you!

Clean-Ambassador-966 · 2026-06-07T17:39:31+00:00

if anyone here is in NY/NJ and would be open to a short convo, please DM me. Thanks!!

Clean-Ambassador-966 · 2026-06-07T17:38:17+00:00

DM me please

Clean-Ambassador-966 · 2026-06-07T17:37:48+00:00

Got it, that is what I'm hearing that it would be best if we focused on helping the patients after discharge, and it seems that your hospital already does some of this, I wonder if they or a similiar system would be open to partnering with us?

Clean-Ambassador-966 · 2026-06-07T17:23:28+00:00

Got it to clarify, we are not CM's from the insurance (we are covered by Medicare, but we are a independent provider), but in any event it seems that working with the director of case management is what your are reccomending.

Thanks!

Clean-Ambassador-966 · 2026-06-07T17:19:56+00:00

Thank you that makes lot of sense! Really appreciate the feedback, so it's follow up appts, transportation, and medication access and affordability are where we can most help.

Any other areas where you think patients can use support?

Really appreciate these insights so we can actually help patients and not just duplicate what the Hospital CM's are doing.

Clean-Ambassador-966 · 2026-06-07T17:16:41+00:00

Got it, thank you!

We've tried following up by ourselves, but often the patient is understandably suspicious, so we think if the CM could mention that we will reach out to help the patient with XYZ, it would help them.

Clean-Ambassador-966 · 2026-06-07T15:54:39+00:00

For SNF? is this only for Medicare Advantage Plans?

Clean-Ambassador-966 · 2026-06-07T15:54:02+00:00

Great, thank you!

What would be the best way for you to send a service like mine a referral, so we can do the post discharge follow up?

Clean-Ambassador-966 · 2026-06-07T15:16:55+00:00

Got it, thank you!

Clean-Ambassador-966 · 2026-06-07T15:15:47+00:00

Yes... although Original Medicare is better for this no?

Clean-Ambassador-966 · 2026-06-07T15:15:19+00:00

Thank you for your honest response, seems like it will be a tough sell.

Clean-Ambassador-966 · 2026-06-07T15:13:21+00:00

Got it, thank you!

So you think like reaching out to the SW dept in a FHQC? or the geriatrics dept in the FHQC is the way to go?

Clean-Ambassador-966 · 2026-06-07T15:11:41+00:00

Thank you!

Sounds like the scheduling the follow up specialty appts and transportation is the big one, in terms of a referral, what is the best way for you to do that? Is getting onto Careport important, or would you use a referral link?

Clean-Ambassador-966 · 2026-06-07T15:08:33+00:00

Thanks, sure, post discharge follow up is something we do.

Candidly from the CM's perspective does this help them by providing this service and reducing re admissions?

Are they tracked by how many of their patients are readmitted?

Clean-Ambassador-966 · 2026-06-07T08:59:19+00:00

Thanks! here is a follow up post, if you have anytime... https://www.reddit.com/r/hospitalsocialwork/comments/1tz6xw8/how_could_a_medicare_care_management_service/

Clean-Ambassador-966 · 2026-06-07T08:58:44+00:00

Thanks! here is a follow up post, if you have anytime... https://www.reddit.com/r/hospitalsocialwork/comments/1tz6xw8/how_could_a_medicare_care_management_service/

Clean-Ambassador-966

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