Care Transition Program
The Care Transitions Program at St. Joseph and Redwood Memorial Hospitalsassists people during times of transition between hospital and home. The programoffers individual coaching and interventions to select populations of patients withan overall goal of providing individuals the tools needed to become active partnersin their health management, especially during times of transition between healthcare settings.
Medication self-management, personal health record keeping, diseaseprocess education, support for follow-up visits and respite housing are some of theinterventions provided. The Care Transitions Program team coordinates planning ofservices with inpatient discharge planning as well as the emergency department,then works with patients outside of the hospital setting. The care and servicesprovided by the team are focused on a community-based, multi-disciplinaryapproach, linking individuals to the various resources available to help meetongoing health care needs.
Services are voluntary and provided free of charge to patients