Care that goes beyond our walls

Care management extends quality care beyond the hospital’s four walls by working with patients in their homes or by phone. We develop a detailed discharge plan to manage the transition back to your home or another care facility. 

Our experienced teams also offer the following outpatient services:

  • Proactive disease management.
  • Wellness education.
  • Health assessments. 
  • Home safety checks.
  • Medication review.
  • Disease-specific education.
  • Discharge clinic.
  • Care Beyond Walls and Wires

Scheduling care after discharge

Our care management teams can arrange any medical care services that may be required after you leave the hospital. These services include:

  • Acute and subacute rehabilitation.
  • Homecare needs.
  • Home infusion and IV therapy.
  • Nursing home, palliative care and hospice care.
  • Home medical equipment.
  • Follow-up appointment scheduling.

Our transition programs

The Care Management organization for Northern Arizona Healthcare has created programs to assist with your transition out of the hospital into continued patient care. These programs prevent hospital readmission while promoting patient wellness.

Project BOOST Flagstaff
This comprehensive program focuses on safely transitioning older adults out of the hospital. The program includes individual assessments for readmission risk and patient care education.

Congestive Heart Failure or CHF Wellness Program
This six-week outpatient program is dedicated to educating heart failure patients on health management and the use of telemedicine services.

Community Care Network
After discharge from Verde Valley Medical Center, patients in this program receive health assessments, home safety checks, nutrition support and other wellness services designed to help them stay well. 

Verde Valley Discharge Clinic
This clinic provides follow-up appointments for patients within five days of their discharge from the hospital. These appointments are designed to assess patients' medical needs and prevent potential issues during their recovery.

Community Integrated Paramedics
The Community Integrated Paramedics program in the Verde Valley makes it possible for specially trained paramedics to visit patients at home to monitor their health and living situation, while helping them navigate the healthcare system.

Verde Valley Caregivers
More than 300 volunteers work for this program, supporting discharged patients by providing medication reconciliation, homecare, transportation to other follow-up and therapy appointments, and more.