MaineHealth Waldo Hospital provides free population health programs in our community. We help support the medical, psychological, social and financial needs of underserved community members through:
- Care transitions
- Care management
- Health and wellness coaching
- Targeted outreach
Caring for our community
Our team includes patient care coordinators, licensed social workers, registered nurse care coordinator/discharge planners, registered nurse care managers and the Belfast Public Health Nursing Association. We partner with local health and human service agencies to achieve shared population health improvement goals.
More about our services
This program offers nursing support for patients recently discharged from the hospital who do not have other support services. An RN will call and offer a home visit to review:
- Medications
- Hospital discharge instructions
- Ongoing health issues
- Additional resource needs
- Confirmation of a follow-up appointment
Additional home visits or phone follow up may be offered if continued need exists.
Care management is designed to help patients (and caregivers) better understand their medical conditions. We can help with:
- Care coordination
- Chronic disease education and management
- Complex care management
- Medication review and education
- Assistance with completing advance care directives, insurance paperwork, MaineCare applications, etc.
- Help with other needs:
- Food insecurity
- Housing
- Transportation
- Medication access
- Literacy
Our staff can help you with healthy living lifestyle choices like nutrition, exercise, stress relief, tobacco cessation or chronic illness management.
It’s our goal to help all patients live the healthiest life possible. We use quality data mining reports to help medical providers find patients who may be due for health screenings such as:
- Breast Cancer
- Colorectal Cancer
- Depression
- Falls
- HgbA1c
And preventative care such as:
- Immunizations
- Diabetic Eye Exam
- Tobacco use
- Annual Wellness Visit