Care coordination after discharge

A nurse care manager or social worker will meet with patients shortly after hospital admission to perform an assessment of needs after discharge from the hospital. They will also encourage patients to include a caregiver, someone who will help them after discharge from the hospital, to be a part of these interactions.

The Social Work/Care Management Team works with patients, families and the clinical care team to assess, plan, facilitate and advocate for services that you need and arrange for post- discharge care while you are still at the hospital.

Some patients with more complex discharge needs may receive a phone call and/or a visit from a member of the care management team post-discharge to ensure your post-acute care needs are met and assist in ensuring your goals of care are met. This might include helping you navigate the healthcare system and accessing care in the appropriate setting as well as such things as accompanying you to medical visits if needed, helping you understand your medications regime or discharge instructions.

Every patient in need of post-hospital services is given a written copy of his or her discharge plan upon leaving the hospital. These may include:

Please keep in mind that it is very important to have family members or friends available to transport you home when your physician discharges you.

A Guide to Post-Acute Care

The Massachusetts Health & Hospital Association has compiled information to support you and your family in making confident health care decisions following a hospital visit.

Patient Questionnaire

Shortly after discharge, you may receive a questionnaire inquiring about your treatment and care at Emerson Hospital. If you do not receive a questionnaire and would like to comment on your care, please write to:

Patient Care Assessment
Emerson Hospital 
133 Old Road to Nine Acre Corner
Concord, MA 01742

We appreciate your comments and suggestions to help us evaluate and improve the quality of our services.

Making a donation

For information on how to make a financial contribution to the hospital, please visit our Giving section.