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Coordinating your care after discharge: what it's all about

Coordinating your care after discharge: what it's all about

After an inpatient stay or an Emergency Department (ED) visit at Methodist Health, you may receive a phone call from one of our highly skilled, experienced Registered Nurse Care Coordinators. The Care Coordinators, who have direct communication with each Methodist Health Primary Care Physician (PCP), may provide disease education as well as referrals for supplemental services, diagnostic testing, medication instruction or modifications of current treatments upon physician approval.

Does my PCP have a Care Coordinator for their office?
All Methodist Family Medicine and Methodist Pediatric locations have a designated Registered Nurse that serves as a Care Coordinator. Methodist Family Medicine Care Coordinators include Tiffany Smith, RN; Chanda Smock, RN; Jenny Phillips, RN; and Christy Stone, RN. Rebekah Jarvis, RN, serves as a Care Coordinator for Methodist Pediatrics.

Why is it important to communicate with the Care Coordinator after a Hospital or ED discharge?
Health systems are often complex and difficult for many patients to navigate alone. Your Care Coordinator will help alleviate any confusion regarding discharge instructions, medication changes, follow up appointments and can even help access resources needed to ensure you get the best care possible.

How long after an inpatient discharge does the Care Coordinator follow my care?
It is the Care Coordinator’s goal to address any and all needs after discharge. They will communicate with you to help coordinate any care you may need for at least 30 days after discharge, which helps reduce the risk of unnecessary readmissions to the Hospital.

I’ve received calls from my PCPs Care Coordinator but I haven’t had a Hospital stay. Why are they calling me?
Care Coordinators may call you if you haven’t had your recommended preventive testing completed based on your risk factors, age and sex. Screenings may include tests such as mammograms, colonoscopies, vaccines, diabetic screenings and cardiac risk testing. It is our goal to keep our community as healthy as possible and catch any abnormalities early by encouraging patients to have their preventive screenings completed.

About Tiffany Smith, RN, Population Health Coordinator
Tiffany Smith is a Registered Nurse who manages the Care Coordinator program at Methodist Health. Since the program was initiated in 2015, Smith has helped build the program from the ground up. For more information about the Care Coordinator program at Methodist Health, contact Smith at 270-826-6822.