Population Health Management

Population Health Management > Post – Acute Transitions in Care Program

Managing your health can be challenging.
Our Post-Acute Care Managers are here to help.

What is a Post-Acute Care Manager?
  • A Licensed Practical Nurse who will help you plan your return home by working with your primary doctor and a healthcare team member at your
    nursing facility.
  • Someone you can call with questions about your health and your care plan.
  • Someone who shares information between your primary care physician and other medical specialists.
  • Your health education resource when you need to make decisions about your health.
What Will My Care Manager Do For Me?

Think of your Care Manager as a partner who will support you and your family to plan a safe return home. Care Managers will work with your facility’s discharge
planning team to:

  • Review your care plan regularly and monitor your progress towards returning home.
  • Review your discharge plan to be sure that it includes the services and equipment that you’ll need to safely return home.
  • Make sure that a follow up appointment with your doctor has been scheduled for 7-10 days after you’ve returned home.
  • Talk to your primary doctor about your progress and your return home from the nursing facility.
What Can I Expect Once I Go Home?

Once you return home, your Care Manager will call you within 2-3 days to:

  • Ask about your health, recovery and transition home.
  • Ask if the homecare agency has reviewed your medication list with you. The Care Manager will review your medication list with you if homecare is not part of your discharge plan.
  • Confirm that you can get your medications from the pharmacy.
  • Confirm that all new equipment (shower chair, walker, etc.) has arrived.
  • Confirm that your follow up appointment is scheduled and that you can get to the appointment.
  • Schedule follow up appointments with specialists or other providers, if needed.
  • Contact your homecare agency, if you have one, to confirm when your services will begin.
  • Get answers to your questions about homecare, equipment, lab draws, appointments or anything related to your health and transition home.
  • Find additional community or social service resources that can support you in your recovery, if needed.

Your Care Manager will call you at least twice during your first month back home to check in on your recovery and provide support when needed.

How Much Does This Service Cost?

This is a free service provided by Saint Francis Healthcare Partners on behalf of your primary care physician.

In Case of a Medical Emergency:

Your Care Manager does not replace medical assistance or your physician’s advice. If you are experiencing symptoms that concern you, please call your doctor immediately.

Long-Term Acute-Care Hospital

Inpatient Rehabilitation Facility

Skilled Nursing Facilities

East Hartford
West Hartford

Home Health

Post-acute affiliations developed in conjunction with Saint Francis Healthcare Partners and Saint Francis Hospital and Medical Center have no financial relationship with any of the facilities listed, with the exception of Masonicare Partners and Mount Sinai Rehabilitation Hospital.