If you or a loved one is leaving the hospital soon, it’s important to know that the transition from the hospital to home can be a challenging time. Care in Transition (CIT) provides evidenced-based Transitional Care Management (TCM), a patient focused program that provides coordinated care and support to patients
who are transitioning from the hospital to home (or community setting).
Our goals at CIT are to help you:
1. Stay safe and stable at home to avoid unnecessary visits to the hospital.
2. Set goals for your health.
3. Prepare for routine visits to your primary care doctor.
4. Answer questions and concerns you may have regarding your condition(s).
5. Learn about your symptoms and how to treat them.
6. Teach you about your health condition and your medications.
How Does TCM Work?
A Transitional Care Nurse Specialist will visit you at the hospital or at home to
confirm eligibility and explain the benefits of the program. Then a home nurse visit will be set up to evaluate your needs.
