Seton Total Health (STH) is a DSRIP (Delivery System Reform Incentive Payment) program operated by the Seton Family of Hospitals. This valuable program works to assist the unfunded/underfunded population find the medical care they need after leaving the hospital. The program was created for people with no insurance or inadequate coverage who have a serious injury or disease that forces them to visit the emergency department or local hospital to receive medical treatment. Seton Total Health works with these vulnerable patients to identify ways they can assist in improving their health using available community resources.

STH program team members assist patients in navigating the healthcare system, help them identify and overcome barriers (such as difficulty obtaining medications or in finding transportation to appointments) and provide care in STH offices and patient homes.

Some patients may only need to stay in the program for a brief time, while other patients may stay for much longer. The goal of the program is to provide patients with tools and information they can use to take care of themselves. It links them with community clinics and programs that can help them manage their medical care over the long term.

We work with members of the patient’s healthcare team at Seton hospitals to enroll patients into our program before they leave the hospital. We discuss our program at the bedside, consent the patient and give the patient their appointments with our team before they leave. Within the first seven days after discharge we ensure the patient has an appointment with their primary care physician and if they do not have one or cannot get in, we make them an appointment with a provider in our clinic. Within the first 30 days of enrollment into our program we work to:

  • Find the patient a primary care physician and make their first appointment.
  • Assist with funding (make MAP appointment for patient, etc.).
  • Ensure the patient is able to obtain/pay for their medication.
  • Provide resources for housing, counseling (ATCIC), food banks, transportation, etc.
  • RN will call patient post hospital discharge to “check-in” and make sure the patient understands and is taking their medications, and to see if they have any questions.