HealthLink at Saint Agnes Hospital
HealthLink is a partnership between Saint Agnes Healthcare and HealthCare Access Maryland (HCAM) to provide community-based, post discharge care management services for individuals with multiple high risk chronic conditions. The HealthLink program is designed to provide customized services to meet each client’s needs, including: insurance enrollment (if necessary); health care system navigation; in-home assessment of risk level; customized care planning; community-based activities; appointment follow-up; prescription attainment and medication reconciliation; Connection to community resources; and coordination of specialty care (behavioral health & supportive services). The program serves patients affiliated with the Saint Agnes Hospital, a 296-bed, full-service teaching hospital with residency programs in a number of medical and surgical specialties.
Clients enrolled in this program provided by this program include, but are not limited to:
• Post-hospital discharge care instructions
• Connecting to primary care/ specialty provider (PCP)
• Arranging transportation
• Housing resources
• Scheduling appointments
• Insurance enrollment
• Medication management
• Access to a 24-hour nurse line
• Food resources
The HealthLink team consists of two registered nurses and one care coordination associate:
- HealthLink Registered Nurses assure continuity of healthcare services by integration of the principles of evidenced-based practice that promote appropriate utilization of healthcare resources and facilitate health education, health promotion and chronic disease management.
- HealthLink Care Coordination Associates assist program participants with accessing health related services, including, but not limited to obtaining a medical home and overcoming barriers to obtaining needed medical care and social services.
Through this integrated approach to care management and community outreach, the HealthLink team supports Saint Agnes Healthcare through consultation and interaction with hospital care management, physician providers, as well as local state and community agencies.