Care Transitions

Everything You Need to Know After Discharge

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 receive 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 community resources
  • Educating patients on medicine management
  • Improving communication between patient and doctor
  • Scheduling visits within 24-72 hours of discharge

Community Resources

Contact:

  • RN Navigator
    • Direct: (559) 791-3849
  • Care Transition Coaches
    • Direct: (559) 788-6146
    • Cell: (559) 920-4513
  • Other
    • Cell: (559) 920-1600

For a full list of resources available to you for issues such as diabetes, chronic kidney disease, chronic heart failure, and other medical conditions, please click here.