Transitions in Care FAQs

The Transitional Care Clinic helps ease the process of hospital discharge for your patients who cannot connect with a medical home within seven days of leaving the hospital.

Our goal is to work closely with you to help manage your patient's care until they can establish their relationship with their primary care office.

We encourage you to learn more about the NHRMC Transitional Care Clinic and look over some frequently asked questions. We also welcome you to submit any additional questions.

How is this clinic different from my medical practice?

We provide a multidisciplinary approach to patient care beyond just a physician visit. During the visit patients are seen by a pharmacist and case manager.

Before and after visits, when necessary, a community paramedic will conduct house visits. If clinical concerns are detected at these house visits we can video conference real-time with a provider and triage those concerns.

We are comfortable managing diagnoses including CHF, utilizing protocols involving IV Lasix at the clinic and during house visits. We also have protocols in place to manage acute COPD exacerbations and chronic COPD. We focus on providing seamless delivery of care and communicating both with inpatient hospital care teams and outpatient providers.

Is there is a financial incentive for the hospital to see these hospital discharges and provide these transition visits?

The clinic was designed with a focus on value-based care and not fee-for-service. We want to keep patients well in the outpatient arena. Our success is not going to be measured in dollars collected but instead in reduced readmissions, improved patient health and enhanced hospital throughput.

Will the clinic serve as a primary care practice for these patients?

We are not a primary care practice. We will see patients in the clinic for 30-45 days following discharge.

During this time, we will work with patients to safely transition them back to their medical home. If they do not have a primary care provider, we will help connect them to a primary care office.

How will I know if you saw my patient?

Once we see your patient, we will fax our Transitional Care visit notes and labs to your office after seeing each patient. For patients needing additional or immediate follow up we will reach out to your office directly.

How do patients get to your clinic?

Before they are discharged from the hospital the inpatient care team ensures patients are scheduled for an outpatient follow-up visit within seven days of discharge.

A follow-up visit within seven days of discharge has been proven to reduce hospital readmissions and keep patients well. If patients do not have a care provider to see them within this time frame, a referral is generated to the Transitional Care Clinic.

Our clinic navigator will meet the patient at the bedside before discharge and verify PCP information and discuss the goals of our clinic visit.

What if a patient is scheduled in your clinic and then later gets an appointment with their primary care within seven days of discharge?

Our clinic navigator will cancel the appointment with the Transitional Care Clinic and encourage the patient to keep their follow-up with their PCP.

We will then offer that appointment slot to another patient who needs follow up. We take the time to verify PCP information with the patient at the bedside and to confirm Transitional Care appointment the day before a patient’s scheduled visit.

What if I have a complex medical patient that needs a hospital follow-up appointment in my clinic but I cannot see them within 7 days or provide the intensive disease management or education as you provide in your clinic?

We are happy to take care of these patients in the Transitional Care Clinic and bridge those patients back to you. We have resources to connect them to services if they have certain barriers to follow up.