Care Transitions Outreach Program
UCSF’s Discharge Follow-up Phone Call/Text Team

This program is designed to support you during your transition from hospital to home, complete the discharge process, help get you the right care at the right time, and improve your health care experience.

Why is this important? Leaving the hospital can be a confusing and stressful time for both patients and caregivers. Getting help soon after you leave the hospital can make both you and your caregivers feel less worried and improve your experience.

How the program works

Calls and Texts You’ll Get

  • You will receive an automated phone call within 3 days of leaving the hospital.
  • You can answer this call in English, Spanish, or Cantonese. If you speak a different language, we will call you with an interpreter to understand if you need any help with symptoms, your medicines, or other health issues.
  • Based on your answers to the automated call, our team will know if you need extra help.
  • We will then call you to help with any problems or questions you have. We might work with your providers, social workers, case managers, pharmacists, home health agencies, etc.
  • If you do not answer the automated call, we will try to call again, and you might also get a text message asking the same questions. If you don’t answer any calls or texts, we will look at your health records to decide if we need to call you again.

Questions Asked on the Call/Text

  • Are you having any new symptoms, or symptoms that are getting worse?
  • Do you have any medication questions or concerns?
  • Do you need help getting your new medicines?
  • Do you have questions about your follow-up plan or need the phone number to schedule your appointment or home visit?
  • Do you have any questions about the instructions you were given when you left the hospital?
  • Were you satisfied with your stay at UCSF?
  • Would you like the opportunity to discuss another clinical issue about your hospital stay with a UCSF nurse?

Meet your Care Transitions Outreach Program Team!

Anna Hoyt, RN

Nurse Coordinator

Joan Casey, RN

Nurse Coordinator

Lena Compton, RN, MS

Nurse Coordinator

Michelle Asiano, RN

Nurse Coordinator

Aurora Snyder, RN, MAS

Lead Nurse Coordinator

Regina Hauabook, LCSW

Clinical Social Worker

 

Meg Wheeler, RN, MS

Nurse Manager

Valerie Clinard, PharmD, APh, FAPhA

Professor - Department of Clinical Pharmacy

 

Rebecca Leon, PharmD, APh

Ambulatory Care Clinical Pharmacist

Adjunct Assistant Clinical Professor

Leslie Carstensen Floren, PharmD, PhD, MA, DABCP 

Associate Dean of Fellowships 

Professor of Clinical Pharmacy

Cathi Dennehy, FCSHP

Health Sciences Clinical Professor of Pharmacy

 

Yvette Hellier, PharmD, BCACP

Experiential Education Program Director

Assistant Clinical Professor  

 

Marilyn Stebbins, PharmD, FCSHP

Professor Emeritus of Clinical Pharmacy (Recall)