Navigating the healthcare system can be complex, especially when managing ongoing health conditions or transitioning between different care settings. At Madigan Army Medical Center, we understand these challenges and are dedicated to providing comprehensive support through our patient-centered transitional care case management program. This program is designed to empower you and your family by coordinating your healthcare journey, ensuring you receive the right care, at the right time, in the most supportive environment.
Understanding Patient-Centered Transitional Care Case Management
Case management, at its core, is a collaborative process. Highly skilled Registered Nurses or Social Workers partner with you, your family, and your entire healthcare team. We work diligently to assess your unique healthcare needs, develop a personalized care plan, coordinate necessary services, implement strategies for success, and continuously monitor and evaluate your progress. This patient-centered approach ensures that your voice is heard and your preferences are respected throughout your care experience. Our primary goal is to facilitate seamless transitions and effective communication among all members of your healthcare team, advocating for your needs every step of the way.
Why Patient-Centered Transitional Care Case Management Matters for You
The need for patient-centered transitional care case management arises when individuals face healthcare complexities that require coordinated support. This need is identified through a collaborative discussion involving you, your loved ones or caregivers, your healthcare providers, and our case management professionals. We conduct a thorough assessment that considers your overall health, psychosocial well-being, and utilization of healthcare services and resources. This comprehensive evaluation allows us to tailor our support to your specific situation, particularly when you are transitioning between different levels of care, such as from inpatient to outpatient, or from one specialist to another. By focusing on patient-centeredness, we ensure that your individual needs and goals are at the forefront of the care plan.
How a Case Manager Champions Your Healthcare Transitions
Our dedicated case managers play a vital role in streamlining your healthcare experience, especially during critical transitions. They act as your advocate and guide, offering a range of valuable services:
- Care Coordination Experts: We excel at partnering with your diverse healthcare team, ensuring seamless communication and coordinated care across multiple providers and specialties. This is particularly crucial when you are transitioning between different medical settings or specialists.
- Empowering Informed Decisions: We clearly explain your care options, empowering you to actively participate in making informed decisions about your health journey. Understanding your choices is essential for a patient-centered approach.
- Goal-Oriented Health Management: We collaborate with you to establish and achieve personalized health goals, providing the support and resources necessary for you to take control of your well-being and navigate healthcare transitions effectively.
- Education, Support, and Advocacy: We provide ongoing education, unwavering support, and strong advocacy, ensuring your voice is heard and your needs are met throughout your healthcare journey.
- Family-Centered Approach: We recognize the importance of family involvement and support. We work closely with you and your significant others to ensure everyone is informed and empowered to make collaborative healthcare decisions.
- Seamless Discharge Planning: We meticulously assist with discharge planning, ensuring a smooth and safe transition from hospital or other care facilities back to your home or the next appropriate level of care.
- Facilitating Healthcare Transitions: We specialize in facilitating smooth transitions of your healthcare to other facilities or settings, ensuring continuity of care and minimizing disruptions during these changes.
Is Patient-Centered Transitional Care Case Management Right for You?
You may benefit significantly from patient-centered transitional care case management if you are experiencing:
- Complex Health Challenges: Management of a serious or terminal health condition often requires coordinated care and support, especially during transitions in care settings.
- Multiple Health Conditions: When you are managing several health conditions requiring treatment from multiple specialists, a case manager can streamline your care and ensure all aspects are addressed in a coordinated, patient-centered manner.
- Critical Periods and Healthcare Navigation Support: If you need extra support during a critical period in your health journey, or if you find it challenging to navigate the complexities of the healthcare system, a case manager can provide invaluable assistance, particularly during transitions.
- Challenges Following Your Care Plan: If you are facing difficulties adhering to your prescribed care plan, especially after a transition in care, a case manager can help identify barriers and develop strategies to improve adherence and stabilize your health condition.
Accessing Patient-Centered Transitional Care Case Management Services
If you believe you could benefit from the support of patient-centered transitional care case management, we encourage you to discuss this with your healthcare provider. Your provider can initiate a medical referral request, and one of our dedicated case managers will then reach out to you to begin the process of enhancing your healthcare journey.
Contact Us: Your Patient-Centered Care Team is Ready to Assist
Madigan Case Management
Hours of Operation: Monday – Friday, 7:30 AM to 4:00 PM
Location: Case Management services are conveniently located within Madigan’s Clinics. (See below for specific locations & contact information)
Transitions of Care to Madigan Army Medical Center
Outpatient Services (Monday- Friday 7:30 AM – 4:00 PM): 253-968-3448
Inpatient Services (Available 24/7 for inpatient transfers only): 253-968-1233
General Care Management Services: 253-968-4700
Patient Centered Medical Homes and Soldier Centered Medical Homes: 253-968-3448
Pediatrics: 253-968-4326
Bariatric Pathway: 253-968-0235
Tricare Prime Remote: 253-968-3465
Oncology: 253-968-5117
Puyallup Community Based Medical Home: 253-477-5078/7008
South Sound Community Based Medical Home: 253-477-5115
Embedded Behavioral Health (Active Duty Only)
McChord Embedded Behavioral Health: 253-982-3685
Special Forces Embedded Behavioral Health: 253-966-6104
Rainer Embedded Behavioral Health: 253 -968-4851
2-2 SBCT: 253-967-1481
1-2 Embedded Behavioral Health: 253-966-3640
17th Fires/555 ENBDE BN: 253-967-8283
Psychological spsp Intensive Outpatient Program: 253-968-4305
Child and Family Behavioral Health Services: 253-365-9110
Intrepid Spirit: 253-968-9026/9015
Integrative Pain Management Program: Monday – Friday 7:00 AM – 5:30 PM, 253-968-3499/2543/6952
2nd BN, 75th Ranger Regiment: 253-967-8508
4th BN 160th SOAR: 253-966-6795
Soldier Recovery Unit: 253-967-5338
INPATIENT: Transitional Care Management Services: 253 968-2303
Keep your family’s information current in DEERS to ensure seamless access to these vital services.
