Holistic, compassionate care for patients

A behind-the-scenes look at UF Health Shands Patient and Family Resources

By: Alina Avalos

A patient who lives alone and is experiencing financial hardships and emotional stress walks through our doors seeking medical care. The patient is admitted to one of our hospitals, and the UF Health Shands Patient and Family Resources department steps in to assist.

The department includes about 150 employees who work to ensure holistic, compassionate care for patients and families through advocacy, teamwork, therapeutic intervention and links to community resources.

“Our team takes a close look at each patient’s comprehensive needs,” said Kay Severson, M.S.W., UF Health Shands Case Management and Utilization Review director. “We focus on achieving outcomes within effective and appropriate time frames, while delivering quality and cost-effective care in collaboration with the health care team.”

Team members include case managers, social workers, discharge facilitators, utilization reviewers and pastoral chaplains. Most patients will encounter at least one of these experts during their hospitalization, and the teams often work together to provide the best possible patient experience.

A UF Health Shands case worker and social worker visit with a patient.

(From left) Coleen Booker, B.S.N., R.N., case manager, and Tamara Thomas, LCSW, M.S.W., social worker, were named the Patient and Family Resources department’s case manager and social worker of the year in 2015.

Utilization Review

Once a patient is hospitalized, utilization reviewers analyze the individual’s chart and determine his or her medical necessities and handle insurance concerns to ensure benefits. Utilization reviewers identify any concerning factors — such as a patient who lives alone and needs financial and emotional assistance — and, if needed, a referral is sent to case management.

Case Management

Case managers ensure that patients receive a smooth continuum of care with the right resources. They take a multidisciplinary approach by collaborating with the entire health care team. If an assessment reveals that a patient would benefit from specialized care in a skilled nursing facility following discharge, yet the patient prefers to go home, the case manager would refer the patient to a social worker to support the transition and help address his or her emotional needs.

Social Work Services

When called to help, social workers assess a patient’s psychosocial and environmental stresses and provide direct intervention and support. They help create a plan based on a patient’s specific needs and preferences. In addition to our hospitals, social workers are available in other locations, including the UF Health Medical Plaza and UF Health Davis Cancer Pavilion. In a case like the one outlined above, a social worker would ask questions to determine whether a patient can go home, rather than to a skilled nursing facility. If it is determined that with specific arrangements the patient can be sent home, a discharge facilitator is called to assist with the next step.

Discharge Facilitation

Once the team determines the patient is able to leave the facility, discharge facilitators support the continuum of care by making necessary post-discharge arrangements and ensuring the patient has the proper resources at home to facilitate recovery.

Pastoral Services

Pastoral chaplains are vital members of the team and can assist hospitalized patients and their loved ones during their UF Health Shands experience. During hospitalization, pastoral chaplains can be called on to help patients in a variety of ways. In addition to providing emotional and spiritual support tailored to a patient’s beliefs, they can assist  individuals and families with conflict resolution, end-of-life decisions and moral and ethical concerns relating to health care.