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.