Recently opened, the Center for Transitional Care at Dignity Health Chandler Regional Medical Center was created to assist patients with a smoother transition from the hospital to their home. Intended to work as bridge during a patient’s transition, the center is led by a dedicated internal medicine physician and nurse practitioners who are experienced in caring for patients with complex medical needs.
These patients include people who are considered “high risk” because they have multiple or complicated medical conditions which often require many prescriptions and lengthy hospital stays or recurring emergency room visits.
For patients with complex medical histories such as this or who face difficult social challenges, transitioning home from the hospital can be daunting.
“The goal of the center is really to lessen the stress and anxiety that some patients face when leaving the hospital,” says Bruce Bethancourt MD, chief medical officer for the Dignity Health Medical Group. “Patients who need this type of early medical care following their release from the hospital will be identified and enrolled prior to discharge.”
Once enrolled with Chandler Regional’s Center for Transitional Care, patients will have access to appointments at center, starting within three days after their discharge.
In addition to coordinating with the patient’s primary care physician, the center can also help to identify a doctor for future routine care if a patient does not already have one. The center will also provide as appropriate: medical needs assessments and at home health monitoring, medication education, disease and other care education, and community support services.
Patients with heart failure who are benefitting from a new “community medicine program” offered at Chandler Regional will also be able to work with this new transitional care center. The community medicine program’s unique group is made up of mobile paramedics, nurse practitioners and physician assistants. Thanks to a $12.5 million grant awarded to the Mesa Fire Department by the Centers for Medicare and Medicaid Services, heart failure patients seen at Dignity Health Chandler Regional Medical Center or Mercy Gilbert Medical Center are now being evaluated for the free in-home follow-up program.
“It is our hope that these new programs will help ‘bridge the gap’ by helping to make sure patients have access to the most appropriate level of care for their needs when it is needed,” says Dr. Bethancourt.