When a patient is admitted to a hospital for inpatient care, the quality of that experience depends on far more than the expertise of any single physician. It hinges on a coordinated system where clinical professionals communicate effectively, where patients have guidance through a complex and often unfamiliar process, and where the transition home is carefully planned well before discharge day arrives. HSHS St. Mary’s Hospital Medical Center, located in Green Bay, Wisconsin, has built its inpatient care structure around this recognition. Three interconnected programs—care coordination, patient navigation, and discharge planning—work in concert to define how the hospital serves patients from admission through recovery.
For patients and families trying to understand what distinguishes one hospital’s inpatient model from another, examining these systems in detail reveals a great deal. This article takes a close look at how St. Mary’s Hospital Medical Center structures its inpatient care environment, identifies the key players involved, examines the tools and processes that support them, and explains why each element matters for patient outcomes.
Why Care Coordination Has Become Central to Inpatient Care
Modern hospital stays are complex by nature. A single patient may receive care from a hospitalist, a specialist, registered nurses, physical and occupational therapists, respiratory therapists, pharmacists, social workers, and case managers—sometimes all within a 24-hour period. Without clear communication and deliberate coordination among these professionals, important clinical information can fall through the cracks.
Fragmented care carries real consequences. Research has consistently demonstrated that poor communication between hospital departments is a leading contributor to medication errors, unnecessary test duplication, extended length of stay, and preventable readmissions. These outcomes affect not only individual patients but the overall quality and safety of care that a hospital can reliably deliver.
HSHS St. Mary’s Hospital Medical Center addresses this challenge by embedding care coordination into the structural fabric of its inpatient services. Rather than treating coordination as something that occurs informally or only when problems arise, the hospital has developed formal frameworks designed to bring clinical professionals together around a shared understanding of each patient’s needs, current status, and care goals.
Inpatient Care Coordination at HSHS St. Mary’s Hospital Medical Center
The cornerstone of inpatient care coordination at St. Mary’s Hospital Medical Center is the interdisciplinary care team. This model moves away from siloed departmental thinking and brings together professionals from multiple clinical disciplines to plan and deliver care collectively, rather than working in parallel without a unified approach.
Structured team interactions—commonly referred to as interdisciplinary rounds—typically occur daily. During these meetings, team members review each patient’s current status, discuss any meaningful changes in condition, evaluate the existing care plan, and address potential barriers to a safe and timely discharge. These conversations create a shared clinical understanding that reduces duplication and prevents critical information from being lost as it moves between departments.
The following table outlines the core roles typically represented within an inpatient care team at HSHS St. Mary’s Hospital Medical Center, along with the primary responsibility each role carries:
| Role | Primary Responsibility in Inpatient Care |
|---|---|
| Hospitalist / Attending Physician | Oversees overall medical management and leads care plan decisions throughout the stay |
| Registered Nurse | Administers treatments, monitors patient status continuously, and communicates clinical changes to the team |
| Case Manager | Coordinates post-acute planning, liaises with insurance and payers, and tracks discharge readiness |
| Social Worker | Addresses the social, emotional, and financial barriers that affect both the patient’s care and discharge planning |
| Physical / Occupational Therapist | Evaluates mobility and functional ability; prepares patients for safe, independent functioning at home or in a care facility |
| Clinical Pharmacist | Reviews medications for interactions and safety concerns; educates patients on their prescriptions before discharge |
| Patient Navigator | Guides patients through hospital processes, reduces barriers to understanding, and connects them to needed resources |
| Registered Dietitian | Assesses nutritional needs and delivers tailored dietary education relevant to each patient’s diagnosis and recovery plan |
When each member of this team understands their role clearly and recognizes how it intersects with the responsibilities of others, care delivery becomes more consistent, efficient, and patient-centered. Patients benefit directly from this structure—knowing who is managing each aspect of their care reduces confusion and builds trust in the overall process.
Communication Systems That Drive Coordination
Coordination cannot exist without reliable information flow. St. Mary’s Hospital Medical Center uses electronic health record (EHR) systems to ensure that clinical documentation—physician notes, nursing assessments, imaging results, laboratory findings, and medication records—is accessible across departments and updated in real time, so any care team member can access the most current clinical picture at any point during the stay.
Structured handoff protocols add another critical layer of communication safety. When nursing shifts change or a patient is transferred between units, standardized frameworks—such as Situation, Background, Assessment, and Recommendation (SBAR) handoffs—give the incoming team a clear, organized overview of the patient’s current status, active concerns, and pending tasks. These protocols directly reduce the risk of communication failures that cause avoidable errors or delays in care.
Patient Navigation at St. Mary’s Hospital Medical Center
Patient navigation as a formal healthcare practice traces its origins to the early 1990s, when oncologist Dr. Harold Freeman introduced the concept to help underserved cancer patients move through complex and often intimidating treatment pathways. In the decades since, the model has expanded well beyond oncology. At HSHS St. Mary’s Hospital Medical Center, patient navigators work alongside clinical teams to help patients and their families make sense of what is happening, what comes next, and what resources are available to support them during and after their hospital stay.
Navigators are not clinicians in the prescriptive or diagnostic sense—they do not diagnose or prescribe. Instead, they serve as consistent, accessible points of contact who bridge the gap between patients and a care system that can feel overwhelming. Their value lies in continuity and a practical form of advocacy that clinical staff, operating under significant time pressures, are rarely positioned to provide fully on their own.
The following list describes the primary functions that patient navigators perform within the inpatient setting at HSHS St. Mary’s Hospital Medical Center:
- Helping patients and families understand their diagnosis, treatment plan, and care schedule in clear, accessible, and non-technical language
- Coordinating appointments, specialist referrals, and follow-up care across departments or with outpatient providers
- Identifying and addressing language, literacy, or cultural barriers that may prevent full comprehension of care instructions or discharge plans
- Connecting patients with financial assistance programs, community organizations, and social support services relevant to their situation
- Serving as a communication link between the patient and the broader care team when questions or concerns arise between clinical interactions
- Monitoring for unresolved issues or gaps in understanding that could compromise adherence to treatment or complicate recovery after discharge
- Providing consistent emotional support and a familiar point of contact throughout what is often a stressful and disorienting hospital stay
These functions represent a form of care that the clinical team, however skilled and dedicated, may not always have the time or structural capacity to provide. Patient navigators occupy that gap and, in doing so, meaningfully reduce the anxiety and confusion that can accompany complex inpatient stays.
Who Benefits Most from Patient Navigation
Navigation services tend to have the greatest impact for patients facing particularly complex circumstances. This includes individuals with a serious or newly identified chronic diagnosis, those for whom English is not a primary language, patients managing multiple comorbidities simultaneously, and those with social determinants of health—such as housing instability, limited finances, or lack of transportation—that could undermine their ability to access or sustain care after discharge. St. Mary’s Hospital Medical Center’s approach reflects the well-grounded recognition that clinical excellence alone does not guarantee good outcomes. A patient who receives expert hospital care but lacks the information or resources to manage recovery at home faces avoidable risks, and patient navigation is a direct, structured response to exactly those risks.
Discharge Planning: Preparing Patients for Safe Transitions
In earlier models of hospital care, discharge planning often amounted to printed instructions handed to the patient on departure day. Evidence-based standards have long since moved past that approach. At HSHS St. Mary’s Hospital Medical Center, discharge planning is an ongoing process that begins at or near the time of admission—not a last-minute checklist completed when the physician writes the discharge order.
Early discharge planning gives the care team time to identify barriers before they become urgent—such as the need for home health services, rehabilitation placement, durable medical equipment, or caregiver support. It also gives patients and families adequate time to process information, ask questions, and prepare practically and emotionally for life after the hospital. When discharge planning begins at admission and continues throughout the stay, unnecessary delays and unsafe transitions become far less likely.
Core Components of the Discharge Planning Process
Discharge planning is not a single event but a sequence of deliberate, interconnected steps that unfold across the entire hospital stay. The following table outlines the core stages typically involved in the process at St. Mary’s Hospital Medical Center:
| Stage | Timing | Key Activities |
|---|---|---|
| Initial Assessment | At or near admission | Identify baseline patient needs, home environment, social support systems, and anticipated discharge destination |
| Ongoing Monitoring | Throughout the hospital stay | Track clinical progress, update the estimated discharge timeline, identify and address emerging barriers |
| Resource Identification | Mid-stay | Arrange home health services, rehabilitation placement, or durable medical equipment based on anticipated needs |
| Patient and Family Education | Throughout the stay and pre-discharge | Provide clear instruction on medications, follow-up appointments, activity restrictions, and warning signs to watch for |
| Discharge Summary Preparation | Day before or day of discharge | Compile a comprehensive clinical summary for the receiving provider, specialist, or care facility |
| Follow-Up Coordination | Before and shortly after discharge | Confirm outpatient appointments, connect with the primary care provider, and facilitate any required community referrals |
Each stage of this process builds directly on the one before it, creating a continuous chain of planning that ends with a patient who is informed, equipped, and connected to the support necessary for a safe and successful recovery at home or in a subsequent care setting.
The Role of Case Managers and Social Workers
Two professional roles are especially central to effective discharge planning at HSHS St. Mary’s Hospital Medical Center: case managers and social workers. While their functions share some common ground, each brings a distinct perspective to the discharge process that the other does not fully replicate.
Case managers typically oversee the clinical and logistical side of discharge. They assess a patient’s readiness to transition, facilitate referrals to rehabilitation facilities or home health agencies, ensure post-acute services are authorized and arranged, and liaise with insurance and payer entities regarding coverage for ongoing care.
Social workers focus on the social and emotional dimensions of discharge. They assess each patient’s home environment and support systems, identify financial or logistical barriers, connect patients to community resources, and provide counseling to families managing the weight of a serious diagnosis. Together, these two roles ensure that the patient’s transition from hospital care—whether to home, a skilled nursing facility, or another setting—is as informed and safe as possible.
The Outcomes of Integrated Inpatient Programs
The value of bringing care coordination, patient navigation, and discharge planning together within a unified inpatient framework becomes evident in measurable clinical outcomes. Hospitals that implement these interconnected systems consistently report lower rates of unplanned readmissions, reduced average lengths of stay, higher patient satisfaction scores, and fewer adverse medication events following discharge. These are not peripheral metrics—each one represents a meaningful reduction in patient harm and a meaningful improvement in overall care quality.
For HSHS St. Mary’s Hospital Medical Center, this commitment reflects a broader philosophy: that high-quality healthcare extends well beyond the technical execution of clinical procedures. It includes how clearly patients understand what is happening to them, how supported they feel throughout their stay, and how thoroughly prepared they are to manage their health after discharge. Patient feedback regarding coordination and navigation services consistently highlights reduced anxiety, greater confidence in discharge plans, and genuine appreciation for having a consistent, knowledgeable point of contact during an often disorienting time.
Conclusion
Care coordination, patient navigation, and discharge planning are three of the most consequential—and often least visible—aspects of inpatient hospital care. They do not generate the same attention as advanced surgical techniques or diagnostic breakthroughs, but they profoundly shape whether patients recover well, return to the hospital unnecessarily, or leave feeling that their experience was guided, dignified, and genuinely patient-centered.
HSHS St. Mary’s Hospital Medical Center has approached these systems with clear intention, developing programs that acknowledge the full complexity of what patients encounter during a hospital stay. The interdisciplinary team model, the presence of dedicated patient navigators, and the practice of initiating discharge planning from the first day of admission are not isolated initiatives—they are interconnected expressions of a care philosophy that places the patient at the center of every clinical and operational decision made within the hospital.
For anyone seeking to understand what thoughtful, integrated inpatient care looks like in practice, the programs in place at St. Mary’s Hospital Medical Center offer a clear measure of what modern hospital care can accomplish when coordination, communication, and compassion are built into its foundation.