Case Management

Coordinating your care in the hospital and at home

Your Patient Advocate

At Anna Jaques Hospital, nurses and social workers form the case management team. Our case managers serve as patient advocates. We coordinate your care when you are in the hospital. When you leave, your case manager arranges for any additional services you need and ensures an appropriate and safe return home.

Case Managers

Case managers partner with your health care team to create the best care for you, in the hospital and after discharge.

As your patient advocate, a case manager helps you make decisions about your care. We can help you address concerns with your doctors and nurses. Your case manager also works with you to complete any necessary paperwork.

Your case manager connects you to services within the Beth Israel Lahey Health system and in your local community, such as rehabilitation.

Social Workers

The stress of being in the hospital for an injury or illness can impact your treatment, recovery and transition from one care environment to another. Our social workers offer resources and support to you and your family for many practical and psychosocial needs.

Our social work services include:

  • Coordination of transfers to other facilities for treatment related to substance abuse and mental illness
  • Education and referral to community agencies and support groups
  • Information and assistance with forming advance directives
  • Information on financial assistance programs
  • Referral coordination for adoption and foster care placement
  • Support and counseling to assist you and your family with the emotional and physical stresses of illness, injury and post-hospital care

Coordinating Your Care After the Hospital

Your case manager develops a transition plan to extend your care when you leave the hospital. Our team:

  • Assesses patient and family needs
  • Collaborates with insurance-based case managers
  • Consults with your doctors

Your discharge plan may include arrangements for:

  • Skilled home health care services
  • Transfer to a skilled nursing facility or acute rehab facility

One of the most important tasks your case manager completes is connecting you back to your community, primary care physician and local resources.

If you or your family have questions about your discharge plan, talk with your case manager or social worker, and your doctor. If you disagree with your discharge plan, contact your insurance provider and follow their instructions.

Be sure to call your case manager if any of these situations occur after you leave the hospital:

  • You do not receive a scheduled follow-up visit from the home care agency.
  • Your home health equipment did not arrive as scheduled.
  • You need more help than you anticipated.

We will arrange for any emergency care you may need. Our team can coordinate proper equipment delivery and follow-up appointments.

Contact Us

The case managers and social workers at Anna Jaques Hospital are available to help you seven days a week. Call us at 978-463-1136.

Case Management Services

Whether you need help communicating with your physician or coordinating multiple health care needs, your case manager or social worker helps you arrange for a variety of services.

Rehabilitation Services
  • Acute rehabilitation
  • Outpatient physical, occupational and speech therapy
  • Short-term rehab
Continuing Care Services
  • Emergency response services
  • Hospice care
  • Nursing home placement
  • Respite care
Home Care Services
  • Home care / homemaker services
  • Home IV therapy
  • Meals on Wheels
  • Medical equipment
  • Oxygen therapy
  • Private pay companion services
  • Transportation
Resource Connections
  • Coordination and referral to early intervention
  • Information on Medicare coverage and benefits
  • Support groups and other community resources