Transitional Care Program


Who We Are

Population Care Coordinators are registered nurses who engage high-risk patients for wellness and chronic disease helping you self-manage your chronic conditions. The care team focuses on promoting the patient’s health through education, evaluation of clinical, social, and behavioral health needs and connecting patients with community resources.

How We Can Serve You

We can help:

  • Contact patients at discharge; identify and address clinical, social, educational, and behavioral health care needs.
  • Provide transitional care services by contacting you after your discharge from the hospital for four weeks.
  • Discuss preventive screenings and their importance.
  • Provide education on your chronic diseases such as diabetes, asthma, heart failure, chronic obstructive pulmonary disease (COPD), valvular procedures/surgery, and coronary artery bypass graft (CABG).
  • Review medication lists with patients/caregivers and provide education where needed.
  • Connect patients with community resources.
  • Help you adhere to your plan of care
  • Facilitate patient-centered goal-setting and healthy self-management skills.
  • Use motivational interviewing or behavior modification techniques to facilitate behavior change.
  • Create a patient-centered care plan and re-evaluate patient progress at set intervals.
  • Manage patient care needs for up four weeks or more as needed/requested.

What We Offer

Our Population Health Care Coordinators offer innovative care coordination services for our primary care offices and specialists to support the management of our patients in need through education and engagement.