Following the hospitalization from surgery, illness or injury, Sleepy Eye Medical Center offers transitional care management to provide a bridge between hospital and home.
The goal of our transitional care program is to provide you with tools and support to promote confidence, knowledge and self-management of your condition as you move from hospital to home. Our Transitional Care Manager, also a registered nurse, is trained in care coordination and management of chronic conditions and will work with you in the following ways:
- Ensure medications, services and equipment are in place and properly used
- Ensure prescriptions are filled and no discrepancies exist
- Help maintain a Personal Health Record
- Schedule doctor appointments
- Communicate effectively with members of your health care team (doctors, nurses, therapists, etc.)
- Collaborate with your doctor to establish goals
- Help you understand and self-manage your chronic disease
- Help you follow your treatment plan
- Provide education on “red flags” or warning signs and when to call a doctor
- Serve as a contact for your questions and concerns
Our transitional care program is 30 days and begins with an in-hospital meeting on the day of your discharge. Within two days of leaving the hospital, our Transitional Care Manager will call you to discuss your progress, address any concerns you have and offer a home visit to review your medications and treatment plan. She will also follow-up with you and your doctor, when needed, to ensure effective, ongoing communication between those involved in your care.
Transitional care is billed to your Medicare insurance and is subject to applicable deductibles and copayments. The program is voluntary, and your decision to participate will not affect any health care benefits.
If you have questions or would like to learn more about the program, please call our Transitional Care Manager at 507-794-8436.