Transitional Care Clinic

Avoid complications—and another hospital stay

The Transitional Care Clinic (TCC) coordinates patients’ care after a hospitalization, keeping key medication and diet changes on track. When patients are dealing with chronic conditions, transitioning from the hospital to a nursing facility or back home can be a challenge. If things get missed, patients can end up being readmitted to the hospital, seriously ill again. The TCC prevents this by ensuring patients understand their care plan and enabling doctors to identify issues early on.

Patients love being part of the TCC because they can see all of their caregivers during one appointment, meeting with a:

• Pharmacist
• Hospital medicine physician
• Dietician
• Social worker
• Nurse case manager.

Patients stay in the program for three to six months, seeing their team as often as needed. During visits the team:

• Checks that patients are taking medications appropriately
• Educates them about how nutrition can impact their condition
• Shares information on services they can access (for example, caregiver hours or transportation help)
• Connects them with mental health counseling, as appropriate.

Patients are generally admitted to the TCC on the recommendation of one of our hospital medicine physicians. However, patients and families may also talk to their doctor or provider about who is a good fit for the program. The TCC focuses on serving patients at the highest risk of hospital readmission.

The Transitional Care Clinic provides coordinated, well-rounded care in one location. Doctors and providers help:

• Educate patients about their condition
• Ensure patients understand how to take medications appropriately
• Provide information on diet and nutrition
• Manage issues involving pain, nausea, and other symptoms
• Make referrals to specialists for additional physical, emotional, and psychological support for patients and their families
• Partner with the Palliative Care Department and oversee transitions to hospice, as necessary.

What types of patients are admitted to the Transitional Care Clinic (TCC)?
We support anyone at risk for hospital readmission. This commonly includes patients with chronic conditions such as diabetes, COPD, or advanced cardiovascular disease.

Can’t patients just see their primary care doctor instead?
The TCC provides a more intensive level of care than patients receive during a typical primary care visit. A physician, pharmacist, registered nurse, case manager, dietician and physical therapist may all be involved in an appointment, depending on the patient’s needs.

Are the physicians in the TCC board certified?
Yes, each of our physicians is board certified in internal medicine.