Transitional Care Program 

Referral Criteria

Wondering if your patient is a good candidate for the Transitional Care Program??


1. Is your patient enrolled in one of these two Medicare Advantage insurance plan?  

  • Texas HealthSpring or Cigna HealthSpring

  • Wellcare / Wellcare TexanPlus

2. Does your patient have multiple chronic diseases including:

  • Diabetes Mellitus (DM)

  • Congestive Heart Failure (CHF)

  • Hypertension (HTN)

  • Cerebrovascular Accident (CVA)

  • Peripheral Vascular Disease (PVD)

  • Chronic Kidney Disease (CKD)

  • Chronic Obstructive Pulmonary Disease (COPD)-Emphysema (Emph)

    • Respiratory Failure (RF) is subset


3. Has your patient recently been in the hospital and at risk of a re-admission within the next month? 

4. Does your patient have transportation or mobility issues that prevent them from keeping appointments?

If your patient is enrolled in either plan above and meets any of of the other criteria, they may benefit from participation in the Transitional Care Program. 

Making a referral is EASY....

Referrals can be made directly by calling one of our Program's Enrollment Specialists at 832-476-3900 or by faxing us at 832-476-3990  


Or you can fax the appropriate insurance referral form to the patient’s insurance company. A case manager will coordinate with our office and we will contact your patient for their first visit. PCP's then receive a note from our Clinic Physician explaining the outcome of the first visit and the suggested plan of care.

 Referral requests are typically approved and the patient is enrolled in less than 24 hours.