STAR Network > Coordinated Care

Post-Acute Care Management

During your stay

All of our STAR Network Skilled Nursing Facilities participate in the SOHO HEALTH Post-Acute Care Management program. Our nurses visit each facility weekly to coordinate care for patients of our Primary Care Providers. This includes:

  • Regular review of the patient’s care plan and monitoring of progress towards returning home.
  • Review of patient’s discharge plan to be sure that it includes the services and equipment needed to safely return home.
  • Coordination of a post-discharge follow up appointment with an SFHCP provider within seven days of discharge.

After discharge

Once patients return home, they receive ongoing follow-up from their SOHO HEALTH nurse for a 30-day period post-discharge. Follow up services include:

  • A comprehensive two-day post-discharge call to review transition home.
  • Review of all discharge medications.
  • Confirm that all new equipment (shower chair, walker, etc.) has arrived.
  • Confirm that follow up appointment is scheduled and that you can get to the appointment.
  • Scheduling of follow up appointments with specialists or other providers, if needed.
  • Coordination of additional community or social service resources if needed.
  • 14 and 28 day follow up calls to monitor health status and coordinate care as needed.