Care Coordination

While you are hospitalized, a team of skilled physicians, nurses and other health care professionals will care for you. Another important member of your health care team at St. Peter’s Health Partners is your clinical care coordinator (C3). This registered nurse or licensed social worker will visit with you to help you plan for your needs after leaving the hospital. This may include:

• Transfer to a rehabilitation center, skilled nursing facility or assisted living facility;
• Coordination of home care or hospice; or,
• Delivery of medical equipment.

Choices for Continuing Care

You have the right to participate in decisions affecting your post-discharge needs. You will have choices in selecting the facilities and home care agencies. St. Peter's provides a full continuum of services to meet your needs upon discharge. Your C3 will provide you with the information you need to make these selections.

When You Leave the Hospital

Your physician decides when you are medically ready to leave the hospital. Patients and their families should begin discussions early during the hospital stay about transportation and assistance that may be needed at home. Transportation is covered by insurance when deemed medically necessary by your physician. Your C3 can assist with transportation arrangements and will coordinate post-discharge needs and services.