Care Management
Navigating Care, Together.
Contact Us
Monday – Friday
8:00 AM – 4:00 PM
Saturday – Sunday
9:00 AM – 3:00 PM
Fax: 503.769.2873
casemanagementstaff@santiamhospital.org
Need Community Resources?
Our community resource guide lists local help with housing, food, transportation, utilities, mental health, and more.
How Care Management Helps
The Care Management Department at Santiam Hospital supports patients and their families during hospitalization by focusing on three key areas: discharge planning, resource connection, and medical necessity review.
Our team consists of licensed nurses and community health workers who collaborate closely with the healthcare team, patients, caregivers, and community partners to develop coordinated, patient-centered discharge plans. We prioritize safety, continuity of care, and act as advocates for patients.
How We Help During Your Hospital Stay
Discharge Planning
- Coordinate discharge needs based on your care team’s recommendations and the availability of appropriate services
- Arrange medically necessary in-home services, such as Home Health or Hospice
- Facilitate placement to rehabilitation centers or skilled nursing facilities for continued recovery
- Provide guidance on alternative levels of care, including assisted living, memory care, adult foster homes, or in-home caregiver support
- Arrange for recommended durable medical equipment (DME)
- Clearly communicate discharge plans with patients, families, and the healthcare team
Resource Connection
We screen for social and environmental factors that influence a patient’s overall health, then connect patients with resources for:
- Housing or shelter
- Food access
- Transportation
- Utility assistance
- Personal safety concerns
- Insurance and financial aid
- Mental health
- Substance use
Medical Necessity Review
- Our utilization review nurses monitor your hospital stay to ensure it meets medically necessary criteria based on clinical guidelines and insurance requirements
- Services such as placement in a rehabilitation or skilled nursing facility, ordering of durable medical equipment, and other discharge related needs may require insurance review and approval. This process can affect discharge timing and available options.
Questions about your discharge plan? Call Care Management at 503.769.9245