The Value Based Care team plays an important role in helping patients and families navigate complex healthcare needs, particularly during transitions of care following hospital or emergency department visits. Through ongoing outreach, health assessments, care planning, and coordination with providers and community resources, the team works to ensure patients receive the support they need beyond their medical appointments.
Recently, a Care Manager worked closely with the mother of a Special Needs Child who had experienced multiple hospitalizations. As part of the Value Based Care Program, the Care Manager maintained regular contact with the family, helping the patient’s mother understand next steps in care, address concerns, and navigate services and resources available to support her child.
During follow-up conversations, the patient’s mother shared that the consistent check-ins helped reduce the stress of managing her child’s complex healthcare needs. She appreciated having a dedicated point of contact who understood her family’s situation and could provide guidance when challenges arose. Reflecting on the support she received, the mother told the Care Manager,
“I feel like you are my guardian angel. When I need you, you are always there.”
The Value Based Care team helps bridge gaps in care, improve communication, and provide personalized support to patients and families during some of their most challenging healthcare journeys. Through coordinated, proactive engagement, the team helps patients achieve better health outcomes while ensuring they feel supported every step of the way.
