Office of Patient Care Management (PCM)

Navigating a hospital stay or a complex medical diagnosis can feel like learning a completely new language while juggling a dozen moving parts. Think of the Patient Care Management (PCM) team as your personal medical interpreters, logistical coordinators, and advocacy experts all rolled into one.

During your hospital stay, our team of experienced nurses and dedicated social workers serves as a vital bridge between you, your family, and the medical system. We begin evaluating your physical, psychosocial, and emotional needs the moment you are admitted, working alongside you until you safely transition to your next step of recovery.

Planning for Your Discharge

We believe optimal healing happens at home. Recovering in your home environment with your loved ones is generally more affordable, more comfortable, gives you greater control over your routine, and helps you heal faster. It also frees up critical hospital beds for neighbors in need of emergency care.

Because a safe return home takes preparation, our discharge planning framework begins upon your arrival.

• Early Assessment & Care Plan Development
  • From the moment you are admitted, our care management experts collaborate with your physicians and nurses to build a personalized plan that honors your medical needs and personal health preferences.
• Addressing Barriers to Wellness
  • We work with you to identify any obstacles to your recovery—such as financial constraints, lack of family support, or home safety issues—and connect you with the appropriate education and tools to overcome them.
• Setting Up for Success
  • We coordinate your necessary hometown resource referrals, arrange specialized medical equipment, and help lay the groundwork for your follow-up appointments.

When Returning Directly Home is Not an Option

If your medical needs require a different setting, we will work with you to find a post-acute facility (such as an acute rehabilitation center or a skilled nursing facility) that matches your needs. Our team directly manages the logistics: we confirm facility availability, secure authorization from your insurance provider, transfer your medical data securely, and arrange safe, reliable transportation to your new care setting.

After Your Stay

Your relationship with your care team does not automatically end when you leave. We provide several tools to ensure your recovery stays on track:

• Follow-Up Contact: A few days after leaving, you may receive a phone call or a mailed survey. We will check on how you are feeling, answer questions about your discharge instructions, and gather your feedback on the care you received.
• My Patient Connect: If you provide your email address during admission, you will receive an invitation to register for our digital patient portal. This secure account grants you instant access to your hospital paperwork, clinical notes, and precise discharge instructions.

Contact Information

Office of Patient Care Management
Monday – Friday 7:30 am to 4:00 pm
Phone: 603-481-8709
Fax: 603-238-2217