St. Joseph Hospital - Redwood Memorial Hospital
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Specialties & Services

The Program Process

  • Hospital staff, discharge coordinators and CTP coaches identify clients who may benefit from Care Transitions intervention
  • A referral is made to the CTP team
  • A "Transitions Coach" is assigned and makes contact with the client in the hospital
  • The client is provided CTP information and initial coaching is started if the client is interested in the program
  • Post discharge, clients receive a follow-up phone call and/or home visit from coach
  • Home visit: Coaches help with medication reconciliation, disease process review, update PHR, and support the client in following up with a clinician/specialist
  • Follow-up phone calls at day 2, 4, 7, 14, 30, 60, 90, 120. Coaches answer questions, provide advocacy if necessary, and reinforce the client’s and the clinician’s needs. Additional home visits are scheduled as needed
  • The client-coach relationship is maintained until goals are achieved

Clients Who May Benefit from a Referral to Care Transitions:

  • Those with a new diagnosis impacting health care needs
  • Clients with chronic diseases
  • Those with multiple medications, new medications and/or changes to existing medication regimen
  • Clients with a recent hospitalization or multiple re-admissions
  • Clients with multiple Emergency Department visits
  • Those with multiple clinical specialists or who are without a Primary Care Provider

Referrals to the program are received from physician’s offices and nurses, physicians, and discharge coordinators from St. Joseph and Redwood Memorial hospitals.

To make referrals, contact:
Care Transitions Office
(707) 445-8121, ext. 5751

Sharon Hunter, RN
Care Transitions Program Coordinator
(707) 445-8121, ext. 5750

If you have any questions about this program or would like more information, please contact:
Sharon Hunter, RN or
Tory Starr, RN
Director of Performance Improvement
(707) 445-8121, ext. 5835