how we help hospitals
Become a Hospital Partner
At Heritage Healthwork, we understand the pressure hospitals face when high-need patients rely heavily on the Emergency Department for care. Frequent ED visits not only strain staff and resources but also drive up avoidable costs for hospitals and health plans.
Heritage is here to be a valuable partner in reducing these challenges.
From Bedside to Better Care
Through our Enhanced Care Management (ECM) program, we work alongside hospitals to proactively address the root causes that lead to repeated ED visits and high utilization. By reducing inappropriate ED use, avoidable readmissions, and lengths of stay, we help lower uncompensated care costs for hospitals while also supporting health plans in controlling overall medical spend.
Our team connects with patients directly—often right at the bedside—to build trust and create individualized care plans that extend far beyond the hospital walls. By coordinating medical, behavioral health, and social services, we ensure patients receive the right care in the right setting—improving outcomes, reducing unnecessary utilization, and driving meaningful cost savings across the healthcare system.
How We Help
Heritage is not only committed to immediate action when a Member is in the final stages of hospitalization, but far beyond. We play a vital role every step of the way.
Our role in the ED
- Work with hospital case managers and ED staff to identify eligible members before they leave the hospital.
- Enroll members into Enhanced Care Management (ECM) at the point of discharge.
- Provide warm handoffs so members understand next steps and feel supported leaving the ED.
Transition of Care support
- Review and explain discharge instructions in plain language.
- Coordinate prescriptions, specialty referrals, and follow-up testing.
- Schedule and confirm follow-up appointments with the member’s Primary Care Provider (PCP).
- Address immediate barriers such as transportation, housing insecurity, or behavioral health needs.
Beyond the transition
Heritage has created its own standards of follow up to make sure Members feel seen, and carried even after the initial days.
- Revised Care Plans: Updating care plans to reflect new diagnoses, medications, or discharge instructions and aligning them with the patient’s long-term health goals.
- Continued Primary Care Follow-Up: Scheduling and coordinating PCP or specialist appointments to establish continuity of care.
- Face-to-Face Engagement: Meeting patients in-person within 7–14 days after discharge to reinforce care plans, assess needs, and build trust.
- Medication Management: Reviewing prescriptions, addressing barriers to access, and ensuring patients understand how to take their medications properly
- Long-Term Care Support: Connecting patients to housing, behavioral health, substance use treatment, nutrition, and other social services that stabilize health and reduce future crises.
- Care Team Collaboration: Sharing updates with multi-disciplinary teams involved in Member’s care including hospital staff, PCPs, and health plans to ensure alignment across all providers.
Become a Hospital Partner and transform high-need patient care into measurable results.
Contact us today.
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