The Population Health Utilization and Care Transitions Team is here to make sure you get the best care possible. We are a team of nurse coordinators and a healthcare navigator who work together to help you depending on your health insurance.
How the Program Works
While you’re in the hospital:
- We keep an eye on your stay in the hospital. We help set up visits with your regular provider or specialist for when you leave the hospital.
After you leave the hospital:
- For 30 days after you go home from the hospital, we will check on you with an automated phone call every week. This isn’t a person calling but a system that asks you some questions like:
- Are you feeling any new sickness or feeling worse?
- Are you having any trouble with your medicines?
- Do you have questions about the care you need to follow at home?
- Do you understand the instructions we gave you when you left the hospital?
- Do you have any other health worries?
- If you tell us you have a problem or a question during these calls, one of our nurses will call you back to help you out.
Connecting You to More Help:
- If we think you could use more help from other health programs we offer, we will tell you about them and ask if you want to join. If you say yes, we will help you get connected.
