Partnership began in 2021 between UCSF Division of Geriatrics, UCSF Office of Population Health, and the San Francisco Campus for Jewish Living (SFCJL). Our interdisciplinary UCSF team provides care for patients recently discharged from UCSF to SFCJL for short-term rehabilitation. Our goal is to optimize your post-acute and transitional care needs.
How the Program Works
During Your Stay at SFCJL
- Upon admission to SFCJL from UCSF Health, you will be seen by a physician for an initial health assessment and medication reconciliation to guide your plan of care.
- You will be seen at least once a week by a UCSF provider.
- Most subsequent weekly follow-up visits will be done by our nurse practitioner. They work closely with our attending physicians to optimize your plan of care.
- Our patient navigator will meet with you to assist with care coordination needs such as scheduling follow-up appointments.
- Our team collaborates closely with your SFCJL Care Team (Nursing, Rehabilitation Team, Case Management, Social Work).
- The UCSF team is on-site at SFCJL, Monday-Friday 8AM-5PM excluding holidays.
- There is a facility-wide on-call physician after hours and on the weekends.
- For an urgent issue that comes up after hours, contact your bedside nurse who can contact the physician on call if needed.
Follow Up
- When you leave SFCJL, you will receive a weekly automated phone call for 30 days to ask you about your medications, symptoms, and experience with your stay at SFCJL.
- If you report any issues, a member of our team will reach out to you to assist you.
- A copy of your SNF discharge summary will be sent to your primary care provider/ specialist.
