From Hospital to Community
CareLink Transitional Case Management Services

Hospitals wish to obtain community based case management services for patients discharged from their care with the specific goal of addressing needs through local resources and preventing unnecessary readmissions.

CareLink Transitions partner with local hospitals to provide transitional case management services of a wide variety. Through multiple programs and services, CareLink offers patients and families assistance and support when dealing with behavioral health and medical issues after being discharged from the hospital.

What Does CareLink Transitions Provide?

  • A meeting, near discharge with your patient in the hospital, to begin a relationship and follow that patient for 30 days post discharge
  • Home visits by licensed nurses/case managers to assist you to remain safely in the community
  • Helping you apply for all benefits you may be entitled to receive
  • Assisting you to achieve wellness by coordinating timely and appropriate health services and/or appointments
  • Working collaboratively with you, physicians providers, family/significant others, and other providers to implement a plan of care that meets your needs for quality, safe, and cost effective care
  • Provide transportation services to your post hospital medical appointments, as needed
  • Monitoring and measuring outcomes of transitional case management interventions

*Services will be provided for 30-days following discharge from hospital

CareLink staff are here to help patients after hospital discharge and provide follow-up and supportive services. We will work referred patients and their medical team to monitor and arrange for continued care needs. CareLink specializes in maximizing the wellness of each patient by coordinating the efforts of the patient, the family, the physician, and community resources.


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