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Case Management – Discharge Planning

We give our best to those we serve.

The mission of the Case Management Department at HSS is to provide the highest level of patient care. Through comprehensive assessments, we develop an individualized plan to safely transition patients to the next phase of their care. By working together with the patient’s entire care team, registered nurse case managers and clinical social workers coordinate and facilitate services to achieve each patient’s optimal level of movement and independence.

Case managers and clinical social workers work with patients and their families to coordinate:

If you have any questions or need assistance, please contact the Case Management Department at 212.606.1271 between the hours of 9am and 5pm, Monday through Friday.

Discharge Planning

The majority of patients having surgery at HSS are discharged home. For those patients requiring in-person care, home care services are available. Patients may also receive physical therapy virtually through the HSS@Home program.

Your case manager or clinical social worker will discuss your discharge options, make the necessary referrals for post-discharge services and contact your insurance company regarding benefits and authorizations as needed. Case managers and clinical social workers are also available to discuss with you any worries or concerns you may have related to your planned surgery at HSS.

Home Care

For patients who require home care, case management staff will assist in arranging a referral to an agency of your choice, as well as one that participates with your insurance carrier. Patients typically receive up to two weeks of home physical therapy and registered nurse and home health aide visits if medically needed and if approved by your insurance company. Many insurance companies will only approve one registered nurse evaluation and one physical therapy evaluation in advance. Authorization for additional services will be the responsibility of the home care agency after the initial home evaluation provided by HSS. In order to qualify for home care services, you must be considered homebound. This means that you cannot leave the home except for doctor visits. If you are not homebound, you will need to go to an outpatient facility for services. 

Many insurance plans do not cover home health aide services. Others will consider home health aide services based on the results of an in-home evaluation. These services are not considered primary and will be provided only as long as registered nurse or physical therapy services are also required. A registered nurse or physical therapist will visit your home within 24 hours of your discharge and will complete an assessment. This will determine the need for home health aide services. If determined to be necessary, these home health aide services may not begin for several days. If you feel that you will require assistance managing at home after discharge, you should speak with your family/significant others to determine if they can support you during your transition to home for a minimum of two weeks. 

If you prefer, you can pay privately for additional home health aide services. A list of agencies is available through case management staff. You may also check with friends and your place of worship for alternative means of private-pay home care. Private-pay home care should be arranged prior to hospitalization so that the services are in place at the time of your discharge.

Medical Equipment

Any medical equipment that you might need, such as a wheelchair, walker or hospital bed, can be arranged through HSS. Insurance criteria and authorizations will determine whether the equipment will be covered. Depending on your needs, equipment can be delivered to your home or to the hospital. Some equipment, such as a hip chair, a raised toilet seat and a hip kit, can be ordered prior to your hospitalization so it is available when you are discharged home.


Your Case Manager will discuss with your physician the safest, most appropriate way for your transfer to home or a rehab facility. Most of our patients can travel by car. However, an ambulette (wheelchair transport) or ambulance stretcher transport) can be arranged by the Case Manager if necessary. Insurance usually does not cover transportation by either ambulance or ambulette. Your Case Manager will explore if your benefits cover nonemergent transportation. Even if you have the benefit and authorization is obtained, the insurance company may deny payment due to lack of medical necessity. The insurance companies determine medical necessity when the bill is submitted; after the transportation has been provided. In the event that transportation is not covered, you will be advised of the cost and will need to provide a credit card number to the transportation company prior to discharge.

Medicare does not provide ambulette transport but will provide ambulance transport under certain conditions. Medicare regulations dictate that patients must pay for mileage for ambulance transport if the facility is more than 20 miles away from HSS.