Population Health Management

Population Health Management > Acute Care Transitions- Hospital to Home Program

The Acute Care Transitions program supports patients who have been identified as being high risk for hospital re-admission. An experienced Community Healthcare Navigator meets with the patient during their inpatient stay, works with unit nurses, case managers and the hospitalist team as a cohesive discharge plan is developed. The Community Healthcare Navigator collaborates with the patient to secure a post-discharge follow-up appointment, connects with family and ancillary services to ensure the transition plan to home is smooth, and communicates pertinent information regarding the transition plan to the primary care provider. Patients are contacted within 48 business hours of discharge to review medications and discharge instructions, and to assess the need for Community Healthcare Coach or social work services. Community Healthcare Navigators follow patients through their post-discharge follow-up appointment and for 30 days after discharge to home to ensure that health needs are met and avoidable re-admissions are reduced.