When you are discharged from the hospital, you might find it difficult
to remember the instructions that were given to you.
Our Care Transitions team offers personalized guidance to help patients
achieve their healthcare goals at home.
You will be paired with a Care Transitions Coach and Nurse to help you
manage your healthcare goals.
Through the Care Transitions program, you will also receive a home visit
and follow-up calls so you can smoothly transition to life back at home.
Once home, our services are available to you!
This program includes:
- Developing a Personal Health Record
- Educating patients on their conditions and potential “red flags”
- Ensuring timely physician follow-up care and connecting patients with helpful
- Educating patients on medicine management
- Improving communication between patient and doctor
- Scheduling visits within 24-72 hours of discharge
For a full list of resources available to you for issues such as diabetes,
chronic kidney disease, chronic heart failure, and other medical conditions,
Care Transitions RN Coordinator
Care Transition Coaches
- Direct: (559) 7886146
- Cell: (559) 9204513
- Email: firstname.lastname@example.org
- Cell: (559) 9201600
- Email: email@example.com