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Care Continuum

Care Continuum

Care Continuum staff are RN’s dedicated to helping patients, families and caregivers manage their healthcare as they navigate through the inpatient and ambulatory settings.  This team provides services to ensure that individual needs are met both while discharging from the hospital, and continuing support when patients transition to home or another level of care.  Our commitment is to provide quality care across the continuum of services, together with our patients and caregivers.
The team consists of inpatient case managers/discharge planners, an orthopedic navigator and ambulatory care coordinators.

Being admitted to a hospital can be a daunting experience for patients and their loved ones. But it doesn’t have to be. At North Valley Hospital, we listened to our community’s request of providing staff to help our patients and their families navigate through this experience. Discharge Planners/Case Managers in the hospital work together with everyone involved in caring for our patients to help meet the ultimate goals of the patient’s plan of care, coordinate services needed following discharge, with the goal of ensuring a safe and successful transitions from the hospital.  The staff can be reached at 406-863-3618 with any questions.
The Orthopedic Navigator helps meet the specific needs of our orthopedic surgical patients to stay on path for the best possible outcomes.  We assist with arranging post-surgical follow up care, any rehabilitation needs for our patients, and following up when you are back at home assuring all your needs are met.  Please call 406-863-3606 with any questions.

Care coordinators in our Primary Care Clinics are dedicated to supporting patients and families after discharges from the hospital, helping people stay well, helping managing chronic conditions, and communicating with patient’s team of care givers.

We offer specific programs to help ensure you are connected within days after your discharge with a care coordinator to review your discharge instructions, medications, make sure you have everything you need and can help answer questions prior to your follow up visit with your provider.  

We also have a Chronic Care Management program where a care coordinator will work with you and your provider to help set goals to keep on track of your health, coordinate with your other providers, pharmacists, therapist, or any other members involved in help meeting your optimal health outcomes.  A care coordinator will schedule time with you monthly to visit over the phone, or in the clinic, to review your goals and help meet any needs for you.  Your family members or other care givers are encouraged and welcome to join the conversations as well.  The care coordinators are experts on resources in the community, and can help align you with any needs.
 

Contact Us

They can be contacted at our two primary care locations with any questions:
North Valley Professional Center in Columbia Falls   406-892-3769
Eureka Healthcare Primary Care in Eureka  406-297-7034