Calvert Memorial Hospital created the Transitional Care Program to enhance care for chronically ill patients after they leave the hospital. The innovative community outreach program is designed to:
• Identify patients with chronic conditions (such as diabetes or hypertension) who are at risk for readmission
• Provide them with additional support after they’re discharged
• Connect them with the resources they need to stay healthy
• Reduce preventable hospital readmissions
The program is focused on making sure your transition from the hospital to home is smooth and that all your follow-up care needs are addressed. Each patient is contacted within 72 hours of discharge by the transitional care coordinator. The amount of contact after that is individualized based on patient need.
The Transitional Care Program is intended to ensure that these patients receive the appropriate ongoing care, such as managing special diet needs or prescribed medications. A major benefit of the program is increased coordination of care and communication with the patient’s entire healthcare team about their special needs.