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Community Care Team: Information for Patients

Within days of leaving the hospital, a Community Health Nurse and a Community Health Worker visits you at home to assess your physical health and lifestyle and provides you with connections to community resources based on your needs.

Our team then arranges for you to meet with your primary care provider. If you do not have a provider, our team can help you find one. Our team then work with you and your provider to identify goals and a health action plan that supports your health and fits your lifestyle.

Our team also arranges times to meet with you on a regular basis to help you reach your goals. These appointments may involve meeting with a team member as frequently as once a week. Follow up can occur on the phone, at home or at the doctor’s office.

You can anticipate working with our team for 30 to 90 days, depending on your needs. When you have reached your health goal(s), our team works with your primary care provider to make sure you continue receiving the help and support you need.


  • Works with you and your medical team to set goals for your health
  • Acts as your personal health care advocate
  • Ensures you have a smoother hospital to home transition
  • Connects you with community resources
  • Facilitates your health care activities, including making appointments
  • Coordinates with your primary care provider and specialists
  • Clarifies prescribed medications and how and when to take them
  • Delivers these benefits and more for free


To receive assistance from our Community Care Team, you must meet the following:

  • Be an adult Medicare beneficiary
  • Have had two or more encounters with the hospital in the last 12 months, including observation, inpatient and emergency room visits
  • Live in Howard County
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