The MATCH (Monitor At The Client’s Home) Program meets the need for continued follow-up with patients who have been discharged or have chosen to revoke our services. While patients’ primary care providers are responsible for meeting patients’ medical needs after they leave our care, our MATCH Program Nurse Coordinator will continue to monitor and assess for eligibility for readmission to care.
Who is eligible for the program?
Only patients who have been previously enrolled in By the Bay Health’s care.
Who pays for this service?
There is no charge to clients in the MATCH program.
While in the program, can I receive other home health services?
Yes. If you are a former By the Bay Health patient receiving other services, you may elect to be followed by the MATCH Program.
Contact with the Coordinator
An RN Coordinator will be in contact by phone and make assessment visits as needed Monday–Friday, 8:30 a.m.–5 p.m. If needed, the Coordinator will alert the Primary Care Provider when any changes occur that re-qualify the client for hospice services.
What will the Coordinator Assess?
Weight loss or noticeable decrease in appetite, infections, hospitalization or emergency room visits, multiple calls to medical providers, inability to leave their home due to decreased energy, new need for a walker and/or wheelchair, increased need for caregiving assistance, agitation, delirium and/or confusion, falls and any significant changes in bowel or bladder.
Role of the Primary Care Provider
All medical needs (including wound care and medication management) will be provided by the client’s Primary Care Provider. For emergent or critical care needs, clients or their families should contact the Primary Care Provider or a local hospital.