Helping you manage your health at home.

When you have health issues that require continued care beyond a hospital stay, our Transitional Care team is available to help.

Our team focuses on providing chronic care management, care coordination and educational resources for chronic illnesses and conditions.

If you’ve been diagnosed with or treated for a chronic illness or condition involving your heart, lungs or other vital organs, you may benefit from Transitional Care Services.

Our dedicated team – including nurses, medical assistants and providers – will help ensure that you have the resources you need to manage your health at home and avoid unnecessary hospitalizations.


Meet our Transitional Care team, focused on your recovery from acute illness and continued care for your chronic health conditions.

Wanda Garcia, N.P.

Chronic Care Management, Allergy and Immunology

Sandra Rivera, N.P.

Chronic Care Management

Briana D. Smith, D.N.P.

Chronic Care Management

Margery D. Smith, N.P.

Chronic Care Management

Kaitlin Toner, PA-C

Chronic Care Management

Luz Wiley, D.N.P.

Chronic Care Management

Conditions and Services

You may benefit from our Transitional Care services if you are recovering from or living with these or other chronic or acute conditions:

  • Anemia
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)
  • Diabetes
  • Heart Attack
  • Liver Disease
  • Open-Heart Surgery
  • Pneumonia

With a goal of promoting quality of life through enhanced understanding and management of your acute illness and/or chronic conditions, our Transitional Care team provides you with the tools you need to avoid hospitalizations. We provide different treatments and services, including, but not limited to:

One of the best ways to take care of your health is to learn more about your health condition and how best to manage it. Essential knowledge varies across the myriad of acute or chronic illnesses. Our team can provide education and information to help you recover, manage your chronic condition and achieve and sustain optimal health based on your unique circumstances and needs.

A review of your medications helps you understand the purpose and importance of your prescriptions and ensures that you get the most benefit. Our review will include any over-the-counter medications you are taking and may include changes or adjustments in your medication regimen in order to best address your needs.

Your Transitional Care team will help you recognize and manage symptoms that need attention. When necessary, we will provide or refer you for additional intervention or appropriate care. Early recognition of new or recurring symptoms can lessen their impact and facilitate appropriate management going forward.

Communication is the cornerstone of our interactions with you. Our weekly calls help to ensure that your needs and wants are understood and addressed and enable you to better understand and participate in your own care. This touchpoint helps us monitor your progress and make adjustments to your care as needed.

Our multidisciplinary team of providers is trained to treat chronic wounds. We offer treatment programs to facilitate relief and help heal hard-to-heal wounds – including chronic wounds caused by diabetes, poor circulation, infection, injury or burns.