Transitional Care Services

If you have been diagnosed with a condition such as Congestive Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD), Acute Myocardial Infarction (AMI) or pneumonia, or you have had open heart surgery, you may require a specialized level of care once you are discharged from the hospital. Our transitional care team is available to help you make a successful transition to returning home. They are committed to providing you and your family the quality care and support you deserve.

Our transitional care team consists of nurse practitioners, nurses, medical assistants and a pharmacist. Their goal is to help ensure that you have the resources you need to successfully manage your chronic condition. They provide:

Individualized education specific to your condition.
Medication reviews.
Vital sign monitoring equipment.
Weekly follow-up calls to check on your progress.
Monitoring of your symptoms and intervention if they worsen.
Individual consultation and support from our nurse practitioners.
Assistance with ensuring appropriate and timely follow up care with your primary care provider and specialty providers.

Our transitional care team typically provides these services for 30-45 days following a patient’s
Discharge from the hospital. However, they can extend these services as needed. The goal of the program is to promote quality of life through enhanced understanding and management of your chronic condition.

For more information about Transitional Care Services, please call 928-336-2165.