UnityPoint Health - Meriter - Stoughton Clinic

RN Care Coordinators (RNCC) contact patients within 2 business days of discharge from the hospital, then follow their care for 45 days. With the goal of preventing hospital readmissions, RNCCs assess patient's health status, provide education to patients and their families, reconcile medications, ensure appropriate follow up with Primary Care Physicians and/or specialists and assist with referrals to specialists. RNCCs also communicate and collaborate with specialty clinics, Primary Care Physicians, clinic RNs, social workers, and UW Health APNPs who oversee the care of patients.

Helping Educate and Link the Homeless (HEALTH) program serves as a bridge for unhoused individuals who are uninsured, unemployed, or disconnected from medical and other community services. HEALTH's focus is to connect patients to care and to overcome the barriers preventing patients from continued health care.

The HEALTH Program offers these services at locations throughout our community, adhering to the street medicine model that has remained the core of the program. HEALTH provides care to patients where they are, including but not limited to shelters, clinics, and in our community.

HEALTH's focus is on medical care and will work with our community's homeless services agencies to ensure patients are getting the full array of services available to them.

• The Community Resource Specialists and Social Work team works closely with the clinic providers, who send referrals based on psychosocial needs of their patients. This team provides resource linkage, complex care coordination, and connection to community supports as needed based on the patient.
• They operate out of the primary care clinics, the therapies departments, NICU-follow-up and work closely with the Behavioral Health Consultant team.
• This team also helps facilitate Advanced Care Planning and helping patients completed Health Care Power of Attorney documentation.