Team Helps Ease Transition From Hospital To Home

Our nurses and social workers support you and your family during your hospital stay and after you go home or transition to another level of care.

Your care coordination team:

  • Specializes in the financial, social, emotional and transitional needs associated with hospitalization.
  • Offers assistance with questions about Advance Directives and Organ Donation.
  • Provides assistance after your discharge to help coordinate your care with your physician(s) after you leave the hospital and hopefully prevent any unnecessary readmissions to the hospital.
  • Ensures all of your providers are aware of the changes in the management of your health such as medication changes and test results.
  • Assists with managing prescribed medications.

Your care coordination team helps plan your transition upon discharge:

  • The entire healthcare team, patient and family should know the anticipated transition day shortly following admission to the hospital. This is important so you and your caregiver know what to realistically expect and how to plan and prepare accordingly.
  • The actual day of release from the hospital is extremely important for a safe transition home or to another level of care.
  • Your safety is the primary focus of our healthcare team during this transition. The team makes sure all your follow up plans and medications are in place. If special education is required extra time may be needed. This may take several hours after your physician releases you.
  • Provide you with information about available health care and community resources that could be helpful to you.
  • And, promote preventative care recommendations like scheduling your annual wellness visit, flu and pneumonia shots and mammograms as well as offering coaching on how to manage chronic diseases including referrals to see our Diabetes Education nurse.

If you have any questions during your stay, please speak with your Care Coordinator, nurse or contact Care Coordination at 521-1542. If you have questions for your Outpatient Care Coordination team call 765.599.3109 if your primary care physician is at Northfield Park Primary Care Campus or 765.599.3545 if your primary care physician is at Forest Ridge Medical Pavilion.