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Making the Transition: Coordinating Medical Needs After Leaving the Hospital

November 15, 2019

Integration is the key when it comes to making sure patients get the best health care. To ensure that patients have optimal health results when they leave the hospital, Atlantic Health System offers the Transitions of Care program to patients.

“Our team includes physicians, nurses, care coordinators, social workers, and community health workers to support the physical, behavioral, and social needs of these patients,” says Maureen Sweeney-McDonough, director of care coordination.

As part of the program, patients who are discharged from inpatient care or the emergency department are assisted in coordinating their medical needs. “We put patients at the center of their care,” says Sweeney-McDonough. “Our goal is to ensure patients get the right care, at the right time, in the right setting.”

A Transitions of Care coordinator meets with eligible patients while they are in the hospital to review the treatment plan established by the health care team. “We help in the management of chronic diseases by providing education, reviewing medications and connecting patients to the right level of care,” says Sweeney-McDonough. “We look to get the patient back to their primary care provider’s office within seven to 14 days.”

The team also screens for social determinants of health (SDOH), non-clinical factors that can impact overall health outcomes. This may include the patient’s ability to get food or transportation, or it may be assessing overall safety and social support. While care coordinators are working with a patient, they also enhance quality outcomes by making sure the appropriate preventive screenings have been done, such as a colonoscopy.

The first few days or weeks after a hospital stay can be overwhelming. In addition to making sure the patient’s family is included in the patient’s care, Sweeney-McDonough says, “We focus on helping patients and their families understand what the next steps are in terms of follow-up with their doctor, ensuring patients have the necessary medications and develop confidence to take care of themselves at home. It’s great to watch patients safely make the transition and ensure they are on the best track to reach their health goals.”

To schedule an eligibility screening for the Transitions of Care program, call the care coordination center at 1-855-226-7171.

We focus on helping patients understand what the next steps are in terms of follow-up with their doctor, getting their medications, taking care of themselves at home, just coordinating and navigating the system.”

Maureen Sweeney-McDonough