We receive referrals from several members of the patient’s healthcare team, including, but not limited to:
- Hospital social worker
- Inpatient Case manager
- Community outpatient clinic
- Emergency room staff
- Ambulance or other emergency medical services staff
- Patient (self-referral)
Team members will review each patient’s medical history and meet with the patient to talk about how the STH program can assist them in their healthcare needs. Patients enrolled into the program will be asked to follow a care plan designed with them by the STH team. Clinic notes are then faxed to the patient’s primary care team to ensure collaboration between STH and the patients PCP. The STH plan and clinic notes from our providers can be found in Compass, to assist the hospital team when the patient is readmitted. Patients that have enrolled in our program and have a readmission are seen by a team member while they are in the hospital to discuss their plan and what could have prevented their readmission. Patients are encouraged to “walk-in” to our clinic, instead of using the ED for all non-emergencies. Our clinic is able to provide see patients for same day visits and provide medications, some immunizations, and limited wound care for our patients.