Care Transition Support

The Care Transition Support Program works to:

• improve the transition of patients from the inpatient hospital setting to other care settings after discharge
• reduce ER visits and readmissions
• improve quality of care
• reduce cost

Throughout the program, you are actively involved and your care is coordinated from all settings and providers to ensure optimal outcomes. The key focus of this program is to ensure collaboration between care providers.

Components of this program include:

• assessment of your health needs, goals and preferences; physical, emotional, cognitive and functional capacities and needs; social and environmental considerations
• implementation of an evidence-based plan of transitional care. This plan is initiated at hospital admission, but extends beyond discharge
• tools to gather and appropriately share information across sites of care (i.e., hospital, physician, rehabilitation, etc.)
• patient engagement in planning and executing the plan of care
• referrals and facilitation of care by primary care and specialist providers.  This program is currently offered to employers and health plans who have partnered with HealthChoice. If you would like to learn about this program, please call 901.821.6700 (press 1) or email us .