Comprehensive follow-up and transitional care have become the latest focus for NYS OPWDD, NYS Department of Health, and Southern Tier Connect (STC). When a member visits the emergency room (ER) or is admitted for inpatient care, the care they receive immediately after the visit and in transition is of the utmost importance. At Southern Tier Connect, we prioritize outreach and support for our members and their families after an emergency. For members who have opted to receive this level of support from STC, we want to ensure that you know what you can expect from your care manager after a visit to the ER or admission to the hospital.
When you visit the emergency room or receive inpatient care, your care manager will receive a RHIO alert via our electronic health record. A Regional Health Information Organization (RHIO) is a local hub where a region’s electronic health information is stored and shared between approved entities. If access to your RHIO information is denied, you may directly notify your care manager of any ER visits or inpatient hospitalization stays.
Once notified of an emergency event, your care manager will assist by reaching out within two business days and providing support as needed. Your care manager will establish contact with you or your designated contact through a phone call or preferred contact method. During this contact, your care manager will offer to support you in a variety of ways:
-
-
- By scheduling a telephone or face-to-face visit with you;
- By helping to ensure that you obtain any prescribed medication from your visit;
- By assisting in scheduling any recommended follow-up appointments and arranging transportation to those appointments;
- By providing locations of Walk-In and Urgent Care clinics near you, telehealth websites you can log onto, or ensuring you have the after-hour numbers for clinics or your primary care provider (PCP), if applicable;
- By coordinating with hospital staff to ensure a safe discharge plan;
- By reviewing hospital documents and providing you with educational materials on your diagnosis; and
- By making referrals to additional providers as needed.
-
At Southern Tier Connect, we are proud to provide personal and quality support to our members. We understand that not every emergency room visit may require extensive support from a care manager, so members and their families can decline follow-up care from STC – let your care manager know your needs when they reach out!
If you have any questions, comments, or concerns, please reach out to your care coordination manager or Population Health Coordinator Emily Jackson at jacksone@southerntierconnect.org.