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.

Care Coordination

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

In-Home Care

After your hospital stay, you may require short-term care in your home. This is limited visits, usually 1 to 3 visits a week, when a nurse would come to your home to check on your condition and help you with any issues you may have.

Rehabilitation (Short-Term)

If you need short-term care from a nurse to recover from surgery, an illness, an accident or another medical condition, short-term care in a rehabilitation facility may be available to you based on your insurance coverage. Our social worker can help you determine what type of care you may need in a rehabilitation setting.

Assisted Living

Assisted living facilities provide daily care for certain activities (bathing, dressing, food shopping and cooking) but not full-time, 24-7 medical care. Assisted Living is not usually covered by insurance.

Long-Term Care (Nursing Home)

This is full-time medical care that provides you with continual care for as many of your activities as needed. Your social worker will help you find a long-term care facility that can has the right care for your abilities.

Community Resources

Your case manager and social worker will identify communication resources to meet your needs, but they must work within your doctor's orders and insurance coverage.

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.