Transitional Care Program

The Transitional Care Program standardizes the process for all patient care. This program focuses on patient communication, improved long-term outcomes, and reduction in re-hospitalizations. This model is based on four pillars:

  1. Medication self-management,
  2. Follow up with PCP/Specialist,
  3. Use of Personal Health Record and
  4. Knowledge of red flags/warning signs/symptoms and how to respond.


Those who qualify for this program must meet at least one of the following criteria:

  • Primary diagnosis of heart failure, pneumonia, COPD or AMI, or
  • 75 years or older, or
  • Eight or more medications, or
  • Recent hospitalization(s), or
  • Three or more chronic diseases


  • Emphasizes coordination and continuity of care, prevention and avoidance of complications and close clinical treatment and management
  • Clinician visits patient daily in hospital and begins process of medication management and assures physician follow up
  • Coordination with facilities, physicians, the patient and their family
  • Comprehensive in-hospital planning and home follow up
  • Post discharge Transitional Care Coordinators maintain contact with patient to assure continued compliance and stabilization


  • Thorough physical assessment
  • Comprehensive case management including a single point of contact
  • Care is delivered and coordinated by the same clinicians in hospitals, SNFs and homes, seven days per week using evidence-based protocol with a focus on long-term outcomes
  • Physician protocol compliance
  • Focus on optimal outcomes
  • Single point of contact for coordination of service and reporting
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