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Transitional Care Navigators
Members who are admitted to Renown Regional Medical Center with highly complex discharge needs.
Transitional Care Management
Members with a recent ER visit or hospital discharge from Renown Regional or Renown South Meadows Medical Center.
Assist Members with their discharge planning needs to ensure they are discharged to the appropriate level of care as well as ensuring that applicable home needs are coordinated prior to going home.
Assist members with a telephonic or home-based visit to ensure all needs are met and follow-up care is scheduled after a hospital discharge.
• Assisting members discharging from the hospital or emergency department with setting up home health or coordinating Durable Medical Equipment( DME) delivery
• Coordination of care in skilled nursing and acute rehabilitation
• Ensuring members have timely follow-up care scheduled when transitioning from the hospital to home, or from a post-acute facility( skilled nursing) to home
• Assessing needs and making appropriate referrals
• Reviewing the discharge plan and instructions from providers
• Patient and family education
• Reviewing all medications, including any new medications after a hospitalization
• Reviewing any warning signs or red flags for when to seek care
• Scheduling follow-up with the member’ s Primary Care Provider
• For members who are home-bound, conducting a visit in your home to ensure all needs are being met
If you meet criteria, they will meet with you in your hospital room.
This team does not take inbound calls.
This team is available to members who meet clinical criteria while at Renown Regional.
You have had a hospital discharge or a discharge from Renown Regional Medical Center or South Meadows Medical Center.
You have recently been discharged from the hospital and need assistance coordinating follow-up care.
Members can access Transitional Care Management services by calling 775-982-7222.
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Members who would no longer want to participate in the program they can let their Transitional Care Navigator know or can call 775-982-7222 or 800-336-0123.
Members who would no longer want to participate in the program they can let their Transitional Care Manager know or can call 775-982-7222 or 800-336-0123. – 11 –