Transitional Care Program

Transitional Care Program

Transitioning Home

The Transitional Care Program is designed to assist hospitalized patients with illnesses and conditions — such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and pneumonia — that put them at risk of multiple admissions to the hospital.

As part of the 30-day program, patients at high risk of readmission will receive:

  • a visit from a transitional care coach while they are in the hospital
  • three follow-up calls over the next four weeks from their coach once they arrive home
  • a referral to the Transitional Care Clinic during the time (3-5 days) between their hospital stay and their follow-up appointment with their primary care provider

Benefits for patients who participate in the new program include:

  • increased knowledge and confidence in managing their disease
  • assistance with managing their medications
  • awareness of early warning signs and when to call their doctor after they go home
  • encouragement to keep their follow-up appointments with their primary care provider

For primary care physicians and providers, the program will provide follow-up communication on each patient seen in the Transitional Care Clinic to facilitate greater continuity of care and easier management of patient medication lists.

The services of the Transitional Care Program are available at no additional cost for patients.

The new Transitional Care Clinic is located inside the hospital’s Registration Department in the CRMC North Tower Main Entrance and may be reached by calling 931-783-5895.