Transitional Care Program

From hospital to healthy at home

Discharge from the hospital is a milestone, but many patients still need help navigating a chronic illness or recovery from a procedure at home. The time immediately following hospital discharge is a critical transition time to prevent hospital readmission. The Transitional Care Program offers specialized treatment for those who have just been released from the hospital and who have chronic conditions.

Patients who enroll in this program will benefit from a team of professionals—doctor, nurse care manager, nurse, pharmacist, dietitian and social worker—who will meet with the patient once a week for four weeks as the patient transitions to managing his or her condition or recovery at home.

Please note that this program does not replace a patient’s primary care provider (main doctor), but rather helps to bridge the gap between a hospital stay and a follow-up visit with the primary care provider. If you need help finding a primary care provider, call 1-844-3627 or click here.

What people are saying

“Once a week, for thirty days, I was seen and evaluated by a whole team, including a doctor, nurse, pharmacist, nutritionist and social worker. They were not just interested in my pulmonary recovery, but my overall health. My case care manager has continued to keep in touch after my release from the program. I highly recommend this program to anyone who is released from the hospital with a chronic condition. I’m convinced this program will keep many people from returning to the hospital with a relapse.”

Patient discharged with multifocal pneumonia

“The people, from the check-in staff to the medical staff, are all professional and extremely compassionate and friendly. You feel like you are the most important patient in the world to them.”

Patient with several medical issues discharged after an eight-day hospital stay

“I felt unsure on how to proceed with my recovery. The Transitional Care Team came to my rescue, not only assuring me that I was recovering smoothly, but also adjusting my medications when necessary, checking my incisions and preventing complications that could have occurred. More importantly, they gave me emotional support.”

Patient discharged after open-heart surgery

How may we help you?

Transitional Care Program

Prisma Health Medical Center Clinics
876 W. Faris Rd.
Greenville, SC 29605