Occupational Therapy and Physical Therapy evaluations of a debilitated patient will decide where a patient goes. They check what the patient is capable of doing with regards to activities of daily living [ADLs] and Instrumental activities of daily living [IADLs] and then they recommend if the patient should go to a rehab or a nursing home or home with outpatient physical therapy or home physical therapy.
Case Manager takes care of issues related to patients going home and can arrange Oxygen for COPD and CHF patients, medication coverage by insurance for costly medications, iv antibiotics at home, hospital bed, wheel chair, bedside commode at home etc.
Social Worker takes care of issues related to placement in Assisted Living Facilities, Nursing Homes, Rehabs, Hospice, LTACH etc. Consult them for any patient coming from a facility or going to a facility after PT recommends rehab/SNF at the time of discharge.
Lace Score: Scoring of patients at high risk for readmissions, if >= 11. This is used by Case Managers.