The Transitional Care Program's serves high-risk patients with complex or chronic conditions on an outpatient basis; either at home or in one of our specialty clinics. 

A Fresh Approach to Healthcare

Our clinics operate like other specialty clinics, with Primary Care Physicians and health plans referring appropriate patients to us and our clinics returning patients back to their PCPs upon stabilization or achievement of clinical goals.

The Transitional Care Program is not limited to patients with a specific diagnosis.
 

 

 

 

 

 

 

Services

Our job is to provide the “extra” care that some patients need to break out of the cycle of emergency room visits and hospital admissions. Transitional Care clinic patients will visit the clinic often (sometimes two to three times in the first month). Our clinic schedules allow the doctor to spend an hour or more with new patients and 30 minutes or more with follow-up patients. Nurses provide and oversee care support and patient and caregiver education services. We help address social issues and aid with barriers to care such as transportation issues. We help patients understand and maximize their health plan benefits. The most at-risk patients receive physician-directed telephonic management services. And all patients have 24/7 access to an on-call Nurse Practitioner or Physician. 

 

Coordination

While patients are enrolled in the Transitional Care Program, we are happy to coordinate all of their care, including prescription refills. Patients may choose to see their Primary Care Physician (PCP)  during their Program enrollment for preventive care services or for an occasional follow up, and we encourage this. Patients enrolled in the Program may also be referred to specialists, as needed. 

 

Communication

The PCP will receive progress notes from us after every visit the patient makes to one of our clinics. We welcome the PCP's participation in the care plan. Our providers can be reached  at any time by calling our main clinic number.

 

Discharges

When patients are clinically stable or meet discharge criteria, we will discharge them back to their Primary Care Physician. We will complete a thorough discharge record, including a plan for ongoing care. Patients may also be discharged from the Program if they move into a nursing home setting, enroll in a Hospice program, begin treatment for active cancer or renal failure under the care of an oncologist or nephrologist, or move out of the area.

 

No matter the reason for discharge, the Program will work to ensure a smooth transition of care. Before leaving the Program, all patients receive discharge instructions, an updated copy of their medications, and an ongoing plan of care.

Referrals

We value Primary Care Physicians and Case Managers  as partners in our program. They are the best source of patient referrals, because patients trust their judgment. Plus, PCPs are in the best position to identify patients who may benefit from the Transitional Care Program's services.

Referring patients to our clinics is easy. Referrals can be made directly by calling one of our Program's Enrollment Specialists at 832-476-3900.

 

Typical Clinic patients include those who:

 

  • Are medically complex, with three or more active chronic diseases

  • Have frequent hospitalizations

  • Routinely present to the ER

  • Have a high-maintenance condition like CHF, CAD, DM, or COPD

  • Have a complex condition like PVD, DJD, unstable CHF