Continuing Care

Continuing Care is a care coordination service that contributes to better health outcomes and higher satisfaction for patients.

How the Program Works

The Continuing Care  Program is staffed by highly trained care coordinators. These nurses, social workers and assistants work closely with high-risk and rising-risk patients to promote better management of their health by:

• Developing personalized goals and self-management improvement strategies for patients.
• Helping patients manage and attend their appointments.
• Assessing medication schedules, potential medication risks and patient educational needs.
• Educating patients to better understand their situation and their treatment plan.
• Identifying social and clinical challenges that may lead to avoidable hospital visits.
• Coordinating a transition of care plan between hospitals and outpatient care.
• Assessing behavioral health challenges, including substance use disorder and other mental health issues, and assisting patients with
  getting the care they need.