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

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

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

For more information, call the Transitional Care Department at 931-783-5895.