Care Coordination Services
Our mission as the Care Coordination Department is to coordinate services and resources across the continuum of health care to assist patients in reaching their optimal health.
Care Coordination Around a Hospital Stay
Care Coordination Services is dedicated to helping UnityPoint Health - Meriter patients and their families cope with the variety of emotional, mental and physical issues that may surround and follow a hospital stay.
The Care Coordination team is composed of social workers and Nurse Case Managers. There is no extra charge to Meriter patients or their insurance companies for services provided by Care Coordination Services.
Our Social Work Services
Care Coordination Services team of certified social workers provides the following:
- Help in coping with emotional concerns related to surgery, chronic illness, terminal illness, alcohol and drug problems, domestic violence, and child abuse and neglect.
- Assistance to patients and families adjusting to health changes that are affecting other aspects of life.
- Referrals to mental health providers.
- Assistance with insurance concerns.
- Information about financial resources.
- Assistance during the transition from the hospital to an alternative living setting, such as a nursing home.
- Information on stress management, including meditation and imagery.
- Assistance with end-of-life decisions, including helping patients complete an Advance Medical Directive/Living Will (see above for three forms you can print out).
- Referrals to a wide range of community resources.
- Bereavement support.
Continuing Care Services
Our Nurse Case Managers are registered nurses experienced in home health care, Medicare and insurance coverage for home care services. Community support services available.
Nurse Case Managers provide:
- Assistance in planning for continuing care needs after discharge from the hospital, including home care services, nursing home placement, assisted living options, transportation and medical equipment.
- Referrals to community resources, including home care agencies, hospice, coalitions for older adults, mobile meals and LifeLine.
Outpatient Complex Case Management Program
The Health Services Case Management Program is a clinic-based initiative to assist Meriter primary care patients, their families and the Meriter physicians and staff, in the planning, coordination and management of care services for those with complex medical, social and/or financial needs. More information on this program can be found here.
Services Surrounding Pregnancy and Parenting
Our perinatal social workers help individuals and families respond to the issues that emerge during pregnancy through an infant's first birthday. Some of the concerns are related to:
- High-risk pregnancy
- Premature and sick newborns
- Drug and alcohol use during pregnancy
- Emotional adjustment to becoming a parent
- Teenage pregnancy
- Post-Partum depression
Perinatal social workers are also available to assist families coping with the death of a baby, or loss of a pregnancy through miscarriage, ectopic pregnancy or stillbirth. Our staff strives to reach each and every grieving family from the time of the baby's death, through the period of grieving, and for as long as the family desires.
Do You Need to Find Home Care or an Assisted Living Facility?
Visit our updated Community Resources and Assisted Living Facilities in Wisconsin section. We've included three resource guides with information on services available throughout Wisconsin, as well as information on items to consider when choosing a facility.
Do You Want to Create an Advance Medical Directive?
You can print off Wisconsin-specific forms and learn more about medical directives in our Advance Medical Directive webpage.