Care Transition Program

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The Care Transition Program is available to patients of all ages upon a physician’s order.  A key ingredient of the program is consultation with family members to gain as much information as possible about the internal and external issues regarding the patient.  The Care Transition Program is not disease specific and is a service for patients dealing with multiple medical issues excluding pulmonary disorders. 

We believe our patients are the focal point of our team. We strive to provide individualized, patient-centered care and reduce avoidable hospital readmissions.

Services Provided May Include:

  • Education on specific healthcare needs
  • Encouragement to take an active role in managing your healthcare
  • Information about health warning signs and symptoms
  • Development of plans for how to cope with symptoms
  • Arrangement of transportation
  • Referral to other community resources
  • Assistance with application process for services
  • Medication education
  • Coordinating appointments with primary care physician and specialists
  • Planning for the future

Short-term Intervention

Care Transitions patients generally stay on the program for a period of 30 days following an emergency room visit or hospital discharge. The Care Transitions team, consisting of an APRN and social worker, will help you coordinate your healthcare services and teach you how to manage your healthcare needs. You are encouraged and supported while taking an active role in long-term planning of your personal health wishes and goals. The program encourages you to be physically active and not homebound while receiving services.