Help to access the tools and support you need to reach your health goals.

Imagine you’re hospitalized and dealing with a new illness or diagnosis or sent back to the hospital because your illness has worsened or progressed. You’re unsure about what life after your hospital stay looks like, and the task of managing and navigating this process can be daunting for you and your loved ones.

We can help.

Our transitional care team is a group of professionals led by a nurse care manager who brings patients, families, and doctors together to improve lives and lower healthcare costs to help you successfully manage your health.


It is our goal to support your self-care so that you can remain in your community and out of the hospital.

How does Transitional Care work?

  • Our team first meets with you and your family while you are in the hospital, or shortly after you leave.
  • If you are transferred to a facility or go home with home healthcare services, the team immediately coordinates your care to make sure you have the services you need in place to manage your chronic disease.
  • If you go home with no services, the team will visit you and go over all the instructions you received when you left the hospital. We’ll also review medications, assess your vital signs, and make sure you have an upcoming appointment with your primary care provider.
  • For the next 30 days, the team will be in touch by phone to provide another layer of support.
  • We’ll answer your questions and coordinate follow-up care if your health has worsened.


If you would like more information about Transitions of Care, please call our Intake Team at (207) 777-7740.