Transition of Care
Transitions Made Easier
Our goal is to keep you healthy and out of the hospital. But if a health event causes you to have longer-term care, we have a support system to help you after discharge. From one-on-one outreach to ready-made, home-delivered meals, we’ll help make sure your transition home is smooth.
Going home after an inpatient hospital or skilled nursing facility stay is a relief. But it can also be challenging. You may have new medications or instructions from your providers. You may have a difficult recovery and need help with other tasks.
Your Advantage MD care team will be there to help. We will contact and assist you after your discharge. We can provide education on new diagnoses, help you manage your medications, connect you to community resources, and more. If you have an emergency room visit, we can also help you avoid a readmission.
Mom’s Meals
Enjoy freshly prepared, easy-to-heat, nutritious meals while you recover at home. Mom’s Meals’ menus meet the nutritional requirements of most major health conditions.
This benefit is only available to Advantage MD (HMO) and D-SNP (HMO) members who are discharged from inpatient hospitals or skilled nursing facilities. Advantage MD (HMO) and D-SNP (HMO) members are eligible to receive three meals per day for five days after discharge. Advantage MD Select (HMO) members are eligible to receive 2 meals per day for seven days after discharge.
Advantage MD (HMO) and D-SNP (HMO) members: Your meal plan includes three meals for five days and will be delivered in one shipment. Each balanced meal includes a protein, grain, vegetable, and side(s).
Advantage MD Select (HMO): Your meal plan includes two meals for seven days and will be delivered in one shipment. Each balanced meal includes a protein, grain, vegetable, and side(s).
How does it work?
A Johns Hopkins Advantage MD Care Management representative will reach out to HMO members who have been discharged from inpatient hospitals and skilled nursing facilities.
- If interested in the meal delivery benefit, you will be contacted by Mom’s Meals to coordinate meal delivery at a time that is convenient for you.
- Your meal plan includes three meals for five days and will be delivered in one shipment. Each balanced meal includes a protein, grain, vegetable, and side(s).
If you think you may benefit from these services and would like to refer yourself, or if you have any questions, contact the Care Management Department.
Call: 800-557-6916 and select option 2
Monday – Friday, 8:00 am – 5:00 pm
Email: caremanagement@jhhp.org
You can opt out of Care Management services at any time by contacting us at 800-557-6916 or caremanagement@jhhp.org.
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