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Care Coordination

The Care Coordination Department will help develop your personalized discharge plans depending on your next level of care. These may include in-home care, short-term rehabilitation, assisted living or long-term nursing care.

Planning

Our goal is to ensure that you are discharged at the right time, with the right information and to the right level of care. UM SRH care coordinators and social workers will work closely with you and your caregivers, physicians and other members of the clinical team, as well as with insurance companies and community resources. They will arrange for the services you need, make sure that you understand and can access your medications, and set up follow-up appointments with your primary care provider or appropriate specialists.

Transitional Nurse Navigators

We also provide Transitional Nurse Navigators (TNN) to assist you with complex medical and social needs that may arise after you leave the hospital. If you qualify for this program, a TNN will meet with you prior to discharge to establish goals for post-hospital care and will advocate for your health care needs.

The Care Coordination Department can be reached by calling 410-820-1000, ext. 5785.

If you have questions after leaving the hospital about your discharge plan, please call the Clinical Transition Line, 410-820-1000, ext. 5080.