Community Care Team

The Community Care Team works with patients and their health care providers to improve patient health conditions after their hospital stay. Specifically, the team helps ensure patients have a smooth transition from hospital to home, learn to manage their illness and feel confident in doing so on their own. The team has won numerous awards for outstanding service, including a citation from Governor Hogan, the Daily Record Health Care Hero, Baltimore Magazine Top 50 Nurses, and the JHU School of Nursing Rising Star award.

Our Community Care Team is a comprehensive support system that includes a Community Health Worker, Community Health Nurse and Community Social Worker that are trained, certified and experienced.

The Community Health Worker supports lifestyle and community service needs, such as:

  • Arranging for transportation to appointments
  • Establishing food, financial and housing assistance
  • Coordinating home health care workers
  • Accessing senior programs
  • Helping with proper diet management

The Community Health Nurse supports the physical health of patients, including assessing their health during their first home visit, organizing their medication list, providing information to their health care providers and monitoring their progress.

Some patients may need additional emotional support after their hospital stay. The Community Social Worker supports their mental health well being by assessing their anxiety symptoms, providing informal counseling and making referrals to behavioral health providers.

Learn more about the Community Care Team: