The Problem
Hospital readmissions within 30 days cost the healthcare system billions annually and often result from lack of outpatient follow-up. Patients discharged from MUSC, Roper St. Francis, Trident Medical Center, and Bon Secours without an established primary care provider or psychiatric provider frequently return to the emergency department for conditions that could have been managed in an outpatient setting. The gap between hospital discharge and first outpatient visit is where patients fall through the cracks.
Hope Health Network closes that gap with rapid post-discharge scheduling across all three of our specialized practices.
48-Hour Primary Care Follow-Up
Hope Medical Associates schedules post-discharge primary care follow-up typically within 48 hours of ED or hospital discharge. Our providers perform medication reconciliation (ensuring the patient understands and has access to all prescribed medications), lab follow-up, wound checks, and care plan establishment. For patients without an existing PCP, we establish a long-term medical home — not just a one-time follow-up visit.
Psychiatric Medication Continuation
Hope Behavioral Medicine is often able to schedule psychiatric follow-up within a week of inpatient psychiatric discharge. Patients started on psychiatric medications during inpatient stays need timely outpatient continuation to prevent medication gaps that lead to destabilization and readmission. Our PMHNPs continue the medication regimen, monitor for side effects, and adjust as needed. Telehealth is available for patients who cannot travel to our West Ashley office.
MAT After Overdose
Hope Addiction Medicine accepts warm handoffs from ED social workers for patients presenting after opioid overdose who received naloxone. We can schedule MAT induction within days of discharge — the critical window when motivation for treatment is highest and overdose risk upon return to use is greatest. Buprenorphine bridge prescriptions are available to prevent gaps between ED visit and first MAT appointment.
For Discharge Planners & Case Managers
One phone number — (843) 737-0312 — connects to all three services. We accept faxed referrals with discharge summaries at (843) 737-0313. Our referral coordinator triages to the right practice and schedules the patient. We provide warm handoff capability for same-day or next-day scheduling when clinically urgent.