Care Coordination and Referrals

Comprehensive Care Coordination

In healthcare today, patients are often frustrated because their providers don’t communicate well with them or with one another.  At Aunt Martha’s, we’re commited to keeping every member of the care team on the same page – especially our patients.

Our Care Coordination Team works in collaboration with your Aunt Martha’s primary care provider (PCP) to make sure you get the services you need, whether it’s something we offer ourselves or if we need to make a referral to another provider.  As a recognized Patient Centered Medical Home, we really are all about YOU.

What This Means to You as a Patient:

  • We take complete ownership of the referral process when you are referred to a specialist or a facility
  • Pre-visit planning to ensure appropriate lab tests are done prior to and during each visit to make it efficient and productive
  • Timely reminders to patients on routine follow-up visits and annual physicals
  • Ensuring patients’ preventive care and chronic condition care needs are met using evidence-based guidelines
  • Timely response to patients’ and specialists’ requests
  • Post-hospital discharge support
  • Timely transfer of medical records to and from Aunt Martha’s

Referral Management

We know coordinating care between primary care, specialists, diagnostic facilities, and other healthcare providers can be a complicated task. In the United States, more than a third of patients are referred to a specialist each year. The referral process is often inefficient and poorly coordinated. When you’re trying to take care of yourself or a loved one, complications and frustrations are the last thing you need.

That’s why at Aunt Martha’s we take complete ownership of the referral process. We believe that finding an appropriate and reliable specialist should not be a patient’s concern. As our patient, you can rest assured that when you are referred to a specialist you will be seen by a knowledgeable and experienced provider.  You can also breathe easy knowing that all of the providers you see will be working with the same information, which makes it easier for them to recommend the best course of action for you.

What This Means to You as a Patient:

  • Unless you have a preference, we match you with and refer you to the most appropriate specialist
  • You will be kept informed regarding the status of your referral
  • You will be scheduled for a specialist appointment in an appropriate amount of time
  • You will be seen by a provider who is in-network with your insurance
  • Your Primary Care Provider will receive the office notes from your specialist visit

Ultimately, our goal is to provide you with the best and most highly coordinated care possible. Our Care Coordinators are available to answer any questions you may have and to help ensure you get scheduled for the appointments you need to improve your health and quality of life.

Post Discharge Support

While Aunt Martha’s always tries to eliminate unnecessary Urgent Care, Emergency Room, or hospital visits, there are times when they can’t be avoided. Our team will support you during the critical transitional periods after a hospital discharge to ensure a quick recovery and a reduced possibility of readmission.

Depending on your insurance plan, if Aunt Martha’s is identified as your Primary Care Provider, your care team may be automatically alerted when you are admitted to a hospital. Included in these notifications are the reason for your visit, tests that were performed, findings that were assessed, as well as the attending physician’s recommended plan of care. Regardless of your health coverage, please take one of our cards the next time you are in the clinic and keep it in your wallet just in case of an emergency. This will help to ensure that the important connection is made between the hospital and your Aunt Martha’s care team.