While you are under the care of the experts at UC San Diego Health, our care management team will help you navigate through your hospital stay and provide assistance and resources as your prepare to return to wherever you call 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: Healthcare 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 healthcare 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
Nonmedical / Personal Care Services
- Most often needed when you are unable to leave your home on a routine basis
- Nurses, therapists and social workers may provide services in your home while you recover
- Learn about UC San Diego Health's preferred home health provider,
Skilled Nursing Facilities
- 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
Acute Inpatient Rehabilitation
- 24-hour nursing care and access to short-term rehabilitation after a 3-day or longer hospital stay when you are not quite well enough to return home
- Includes routine visits by a physician
Learn more about skilled nursing care
Long-Term Acute Care
- Intensive rehabilitation program with a plan for 3 hours of therapy, 5 to 7 days / week
- You must be physically able and motivated to participate in a rigorous rehabilitation program
- Includes daily visits by a physician
- A specialty-care hospital designed for patients with serious medical problems that require intense, special treatment for an extended period of time, usually 20 to 30 days
- Helps to improve the quality of life for people with serious or life-threatening conditions
- The goal is to prevent or manage symptoms and side effects of a condition or its treatment
More about palliative care
- 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
- 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