Transitional Care Program


Transitional Care Program 
By the Numbers 

CircleArrow_15px.png  88% transitional care patients keep follow up appointments

CircleArrow_15px.png  60% health center patients are introduced through transitional care

CircleArrow_15px.png  500 people are helped annually to find a medical home

Easing the Transition from Hospital to Home 

Holy Cross Health launched the very successful Transitional Care Program in 2010 to ease the transition from hospital to home—and prevent re-hospitalization—for patients without health insurance and with limited resources. The program is designed to help ensure that the gains patients make while hospitalized continue after discharge.

Follow-Through, Follow-Up 

Patients identified as “at risk” during their discharge interview are referred to the Transitional Care Program. A program team member contacts patients by phone soon after discharge to help navigate next steps in recovery. The Transition Care Health Coach is bilingual to ensure that language isn’t a barrier to continued care.

The program's support nurse assists patients with everything from explaining diagnoses and “doctor’s orders,” to ensuring they have the medications they need. Most important, the team helps to facilitate patients’ follow-up doctor’s appointments at their primary care clinic, or at one of the four Holy Cross Health Centers.

They also make follow-up telephone calls to patients to be sure their recoveries are on track and that they have kept their appointments. If the patient hasn’t yet seen the doctor or missed a scheduled appointment, the support nurse will help them make another appointment and help arrange transportation, if that’s a problem.

Continuing Care 

In addition, the team will follow-up with patients who are spending time in a rehabilitation facility or nursing home after discharge to be sure they receive any needed continuing care.

If patients have no primary care physician, team members will introduce them to the services available at the Holy Cross Health Centers and help them access that care.

To help prevent future problems, the team provides patients with information about Holy Cross Health community-based wellness education, exercise and chronic disease self-management programs.