“Transitions of care” refer to the movement of patients between health care practitioners, settings, and home as their condition and care needs change. For example, a patient might receive care from a primary care physician or specialist in an outpatient setting, then transition to a hospital physician and nursing team during an inpatient admission before moving on to yet another care team at a skilled nursing facility. Finally, the patient might return home, where he or she may receive care from a visiting nurse or support from a family member or friend.
Being discharged from the hospital can be confusing and stressful for patients and their loved ones.
The Family Health Centers’ Care Navigator, Sharon, is here to help with these transitions.
Sharon coordinates medications, medical appointments and self-care following your hospital stay.
Sharon also acts as a single point of contact among your providers while sharing emotional support with you and your family. By smoothing your path to recovery, our Care Navigator helps minimize the need for readmission to the hospital.