In the role of Continuum Care Specialists, our team of licensed practical nurses make telephonic outreach calls to patients within two business days of returning home from a hospitalization. During the outreach call, nurses assess a patient’s Transition of Care by ensuring home safety and supports are in place. The Continuum Care Specialist communicates with the discharging providers and patient’s community providers to obtain and reinforce the discharge plan and to obtain and coordinate prescribed home care services, post-discharge follow-up appointments, and prescription medication as needed during the transition period. The Continuum Care Specialist will make referrals and collaborate with colleagues to identify community resources and supports such as medical transportation, durable medical equipment, caregiver assistance, or meals toward optimal healing and rehabilitation at home after hospitalization. The goal of the Transition of Care management is to reduce readmissions, connect patients with their providers, and identifying patients needing ongoing support and health management.
Read patient stories and experiences.