Social Work and Case Management
Partnering with others to ensure a continuum of care
Caring for the health of each patient is what we do best. Here, entire teams work together to achieve the best possible outcomes. As our patients and their family members prepare to transition to postacute care or for continued services in the community, we partner with preferred providers to make sure patients receive the help they need each step of the way.
Continuum of Care team
The Continuum of Care team includes hospital leadership, social workers, nurses and providers. They partner with specialized areas across the health system to understand the care needs of our patients and to support community partners in meeting those needs. Our postacute medical director helps provide clinical oversight of the Continuum of Care network and coordinates with the hospital team, other specialists and primary care physicians to support our community partners.
How we serve patients and their physicians
- We understand the patient’s medical condition and how each transition affects that patient’s experience.
- We monitor monthly outcomes, provide on-site education and review areas of improvement to ensure quality care is delivered at each level of care.
- We implement clinical care expectations in key areas, including heart failure, diabetes, sepsis, advance care planning and other common patient needs.
- We communicate with the patient’s healthcare team (physicians, nurses and other care providers) about any concerns to prevent hospitalization.
- We help coordinate care by providing access to the patient’s medical record to ensure effective communication for continued care needs.
- We provide care from the postacute geriatric medicine team for those who are recovering from recent hospitalizations at skilled nursing facilities, assisted living communities and long-term care venues.
Our Continuum of Care network
Patients have a choice where they receive their ongoing care. Our Continuum of Care network follows specific quality and service practices and participates in monthly meetings with our health system to support quality outcomes for our mutual patients.
The University of Kansas Health System has identified preferred partners in all levels of care to support our patients in their continued recovery. The care team works with each patient’s physician to understand the recommendations for continued care and helps patients in planning for and arranging services.
For more information, call 913-588-2160.
Continuum of Care network members
- The University of Kansas Health System Home Infusion
- Serves all of Kansas, Missouri and Oklahoma
- Aquinas Carondelet Home Health
- Kansas: Johnson, southeast Leavenworth, northeast Miami, Wyandotte
- Missouri: north Cass, Clay, Jackson, west Lafayette, Platte, portions of Ray
- Golden Belt Home Health and Hospice
- Kansas: Barton, Pawnee, Rush, Stafford
- Home Health by John Knox Village
- Kansas: Douglas, Johnson, Leavenworth, Miami, Wyandotte
- Missouri: Bates, Cass, Clay, Jackson, Johnson, Lafayette
- Midland Care Home Health
- Kansas: Douglas, Franklin, Jackson, Osage, Pawnee, Pottawatomie, Shawnee, Wabaunsee, Wyandotte
- Olathe Medical Home Health
- Kansas: Douglas, Franklin, Jackson, Osage, Pawnee, Pottawatomie, Shawnee, Wabaunsee, Wyandotte
- Visiting Nurses Association of Kansas City
- Kansas: Johnson, Leavenworth, Miami, Wyandotte, portions of Douglas
- Missouri: Cass, Clay, Jackson, Lafayette, Platte, Ray, portions of Bates, Carroll, Henry, Johnson, Pettis, Saline
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Serves the following counties
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Serves the following counties
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Serves the following counties
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Serves the following counties
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Serves the following counties
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Serves the following counties
- Appl Orchard Hospice
- Kansas City Hospice and Palliative Care
- Kansas City Hospice House
12000 Wornall Road
Kansas City, MO 64145
Serves the following counties- Kansas: Johnson, Leavenworth, Wyandotte
- Missouri: Cass, Clay, Jackson, Platte
- NorthCare Hospice and Palliative Care
- NorthCare Hospice House
2800 Clay Edwards Drive
North Kansas City, MO 64116
Serves the following counties- Missouri: Cass, Clay, Jackson, Platte
- The University of Kansas Health System Home Hospice and Hospice House at Olathe Campus
15310 S. Marion St.
Olathe, KS 66061
Serves the following counties- Kansas: Anderson, Johnson, Miami, Douglas, Franklin, Linn, Wyandotte
Cedar Lake Village
15325 S. Lone Elm Road
Olathe, KS 66061
- The University of Kansas Health System
Inpatient Acute Rehabilitation Hospital
3910 Rainbow Blvd.
Kansas City, KS 66160 - The University of Kansas Health System
St. Francis Campus Acute Rehabilitation
1700 SW 7th St.
Topeka, KS 66606 - Lawrence Memorial Hospital
Inpatient Acute Rehabilitation Hospital
325 Maine St.
Lawrence, KS 66044 - Rehabilitation Hospital of Overland Park
5100 Indian Creek Pkwy.
Overland Park, KS 66207
- Kindred Hospital Northland
500 NW 68th St.
Kansas City, MO 64118 - Select Specialty Hospital – Kansas City
1731 N. 90th St.
Kansas City, KS 66112
- The University of Kansas Health System
Multiple locations in Kansas City
St. Francis Campus in Topeka - Rehabilitation Hospital of Overland Park
5100 Indian Creek Pkwy.
Overland Park, KS 66207 - Ability KC
3011 Baltimore Ave.
Kansas City, MO 64108
- Brookdale of Overland Park
12000 Lamar Ave.
Overland Park, KS 66209 - Brookdale Rosehill
12802 Johnson Drive
Shawnee, KS 66216 - Good Samaritan Society – Olathe
20705 W. 151st St.
Olathe, KS 66061 - Hoeger House
20911 W. 153rd St.
Olathe, KS 66061 - Lakeview Village
9100 Park St.
Lenexa, KS 66215 - Lawrence Memorial Hospital
Transitional Care Unit
325 Maine St.
Lawrence, KS 66044