Transitional Care Clinic
Transitional Care Clinic
Information about the Transitional Care Clinic
What is Transitional Care?
Transitions are some of the most delicate moments across the entire spectrum of health. When patients are dealing with chronic ailments and conditions, any extra movement between care providers and settings brings added risk to their health and safety—from a loss of coordinated care, to unavoidable exposure to diseases found in new environments. Even the smallest setback can cause them hospital readmission, creating an unfortunate roadblock on their path to an improved or more stable condition.
Transitional Care addresses a patient’s needs, preferences, and health goals—along with those of his or her family—during times of movement from one care setting to another. This care model focuses on coordination and continuity between practitioners and care settings as a patient’s condition and needs change.
How We Are Different
At the Transitional Care Clinic, we serve patients who are at the highest risk of readmission, including those suffering from serious illness, frailty and social isolation, with consistent, well-rounded care in one location.
Whether they have been discharged from the hospital, referred to us by Internal Medicine, Family Medicine, or Specialty Care Physicians, or are transitioning to and from a skilled nursing facility, they benefit from our multidisciplinary team of doctors and specialists who work as a coordinated group on their behalf.
Our team includes multiple hospitalist physicians, a dedicated RN program coordinator and RN case manager, a medical social worker, medical assistant, nutritional and diabetes educator, respiratory therapist and a physical therapist. Together, they provide patients with a greater level of consistency and coordination, explore the root factors for readmission, and provide corrective measures to help keep readmission from happening.
The multidisciplinary care team includes the following:
- Dr. Joan Hunter
- Dr. David Swenton
- Dr. Lawrence Yuen
- Dr. Vincent Au
- Dr. Craig Riley
- Dr. Catherine Cotten
- Dr. Aaron Kilber
- RN Program Coordinator, John Guile, RN
- RN Case Manager, Alberta Hoechlin, RN
- Medical Social Worker, Fred McGhee, MSW, MDiv
- Medical Assistant, Melissa Reiners, CMA
- Nutrition and Diabetes Education, Natalie Martinez, RD-CDE
- Pharmacy Manager, Larissa Morrow
- Providing coordinated, well-rounded transitional care in one location.
- Managing issues involving pain, nausea, and other symptoms related either to the illness or medical interventions.
- Generating referrals to specialists for physical, emotional and psychological support for patients and their families.
- Overseeing transition to hospice.
What is the target patient population for enrollment in Transitional Care Clinic?
We typically see patients who are dealing with chronic conditions such as diabetes, COPD or advanced cardiovascular disease, and/or those who are at high risk for hospitalization.
Why isn’t a patient seen by a primary care physician for post-discharge care?
The primary care team at The Transitional Care Clinic provides a more intensive level of care than patients will receive during a typical primary care visit. With each visit, a care team that includes physicians, RNs, case managers, nutritional consultants and physical therapists, are equipped to meet the goals and medical needs of patients, especially those dealing with multiple chronic conditions.
Are the physicians in the Transitional Care Clinic board certified?
Yes, each of our physicians is board certified in Internal Medicine.
The Transitional Care Clinic is prepared to see patients as often as necessary over the course of several weeks in order to manage symptoms, adjust medications, and address social concerns. As needed, we work closely with the Palliative Care department to serve the needs of our most symptomatic and chronically ill patients.
Working within the transitional care framework, we seek to provide patients with the support systems they need to avoid further hospitalization. Over time, our goal is to help patients avoid hospital admissions altogether by creating a direct link with the ER.