Our care management team helps you navigate hospital stays and then provides assistance and resources as you prepare to return home.
Our team includes:
- RN care managers: Registered nurses who work in collaboration with your physician to determine when you are medically ready for discharge and make sure you have a safe discharge plan in place. They educate patients and serve as their advocates during the discharge planning process.
- Social workers: Health care professionals with specialized master's degrees who address the emotional and practical concerns of patients. They can help ease the transition back into the community by connecting patients with community resources.
- Administrative and other licensed health care professionals
Options for Post-Hospital Care
Our health care team will partner with you and your family to develop a plan for the next step in your recovery. Collaborating with your health care providers, our care management professionals will help you arrange your after-hospital services.
Below are some options that may be available to you depending on your medical needs, insurance plan, and where you live. Unfortunately, not all services are available in every community.
Home Health Care
- Most often needed when you are unable to leave your home on a routine basis
- Include services provided by nurses, therapists or social workers in your home while you recover
- UC San Diego Health offers home health care through a joint venture with AccentCare
Nonmedical / Personal Care Services
- For daily living assistance, such as bathing, eating, cleaning the home and preparing meals
- Usually not covered by insurance and does not require a prescription from your physician
Skilled Nursing Facilities
- 24-hour skilled nursing care and access to short-term rehabilitation after a hospital stay of three days or longer when you are not quite well enough to return home
- Includes routine visits by a physician
Acute Inpatient Rehabilitation
- Intensive rehabilitation program with a plan for three hours of therapy, five to seven days per week
- You must be physically able and motivated to participate in a rigorous rehabilitation program
- Includes daily visits by a physician
Long-Term Acute Care
- UC San Diego Health offers long-term acute care through a joint venture with Select Specialty Hospitals. This is a specialty-care hospital designed for patients with complex medical problems who require intense, special treatment for an extended period of time.
- Helps to improve the quality of life for people with serious or life-threatening conditions
- Has the goal of preventing or managing symptoms and and side effects of a condition or its treatment (see Palliative Care for details)
- Compassionate care for people facing a life-limiting illness or injury
- Focuses on comfort care, emotional and spiritual support services
- Usually provided in your home
- Pharmacy infusion services: Patients can receive certain types of infusion therapy either at home or at our Kearny Mesa infusion suite.
- Medical equipment: Your physician may prescribe medical equipment for home use. Your care manager will help you determine what your insurance plan covers.
- Transportation: Your case manager or social worker can help you make decisions about your transportation options for leaving the hospital or future appointments.
- For Medicare Advantage, Medi-Cal or private insurance, call the number on your insurance card
- For Medicare A & B, see Medicare