Coordination and Continuity of Care

Care Transition is designed to help ensure the coordination and continuity of care as patients transfer between locations or different levels of care in order to reduce re-hospitalizations and visits to the Emergency Department.


Care Transition provides coaching to help our patients and their families understand a patient’s conditions, effectively articulate their preferences and enable self-management and care planning.

How it Works

A Care Transition Coordinator will assess a patient’s health records for risk factors that would put that patient at an increased risk for re-hospitalization. If a patient is at high risk, the Coordinator will visit with them during their hospital stay and perform an assessment verifying health history and identifying post-discharge needs.

Identifying Needs

During an assessment by a TMC Care Transition Coordinator, patients may be asked questions on the following topics:

  • Medications: review and confirmation of medication lists, identifying high risk medications
  • Medical conditions: discussion of health history
  • Patient support: identifying any social support at home to help care for the patient after discharge and confirmation that a relationship with a healthcare provider or primary care physician has been established
  • Physical/mental health: assessment of any physical and/or mental health limitations
  • Health knowledge: assessment of the patient’s knowledge of their specific medical condition(s)
  • Prior hospitalizations: review history of any hospitalizations or Emergency Department visits within in the past six months of current hospitalization

What to Expect

  • TMC staff will schedule a follow-up appointment for you with your primary care provider
  • Patients will receive a follow-up phone call to verify they have made it home safely and that their healthcare needs are met

Risk Factors

  • 65 years of age and older
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disorder (COPD)
  • Heart Attack (Acute Myocardial Infarction)
  • Stroke (Cerebrovascular Accident)
  • Pneumonia
  • Sepsis
  • Prior hospitalizations and/or Emergency Department visits within six months of current hospitalization

For more information, contact the TMC Care Transition Coordinator at 903-416-4546.