Dedicated CM coordinates discharges for patients.

Montefiore Medical Center in Bronx, NY, has a complex case manager who coordinates post-discharge options for uninsured patients with complex needs. The initiative frees up unit case managers and social workers to manage the care of less complex patients. The hospital has an arrangement with a community-based organization to provide a safe living environment for patients who are homeless and need post-acute services. A complex care advisory team reviews patients with post-discharge issues and makes a recommendation to the hospital's administration.