For Community

Care Transition Program

The Care Transitions Program at St. Joseph and Redwood Memorial Hospital Hospitals assists people during times of transition between hospital and home. The program offers individual coaching and interventions to select populations of patients with an overall goal of providing individuals the tools needed to become active partners in their health management, especially during times of transition between health care settings. Medication self-management, personal health record keeping, disease process education, support for follow-up visits and respite housing are some of the interventions provided.

The Care Transitions Program team coordinates planning of services with inpatient discharge planning as well as the emergency department, then works with patients outside of the hospital setting. The care and services provided by the team are focused on a community-based, multi-disciplinary approach, linking individuals to the various resources available to help meet ongoing health care needs.

Services are voluntary and provided free of charge to patients.

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

Program Process:

  • Hospital staff, discharge coordinators identify clients who may benefit from Care Transitions intervention
  • A referral is made to the CTP team
  • Post discharge, clients receive a follow-up phone call and/or home visit from Care Transitions team
  • Home visit: RN can help with medication reconciliation, disease process review and education, and support the client in following up with a clinician/specialist
  • Social Worker and Health Coach available to provide person-centered care focused on solutions for issues related to social determinants of health, such as lack of financial resources, limited access to primary care, transportation barriers and other necessary community resource needs.
  • Additional home visits are scheduled as needed

· For more information or to make a referral please contact:

Joy Victorine MSW
Care Transitions Program Manager

(707) 445-8121, ext. 5825

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