Transitional Care

For Providers

The goal of the Transitional Care Clinic is to offer necessary care for patients who cannot connect to a medical home within seven days of hospital discharge.

Our Transitional Care providers look forward to working with you to help bridge any gaps in care and help manage patients' care until they can establish with a permanent medical home.

We welcome you to reach out to us with any questions or concerns or to find answers to FAQs.

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The NHRMC Transitional Care Clinic helps you safely get back to your daily life by providing your follow-up care once you get out of the hospital.

If you have had to be admitted to the hospital for treatment of a medical condition, we know that you may need some extra support while you set up a medical home with a primary care provider.

The NHRMC Transitional Care Clinic helps continue your treatment plan to help you stay well until you can safely return to your home and daily life. 

Your Transitional Care Team

While you are being seen at the Transitional Care Clinic, a specialized care team will continue help manage your health and make sure you are connected with a primary care provider. Your team includes:

  • Physician
  • Case Manager
  • Nurse
  • Medical Assistant
  • Pharmacist
  • Community Paramedic

Your team will manage your care and once you have a primary care provider, send your medical records to them so that they can continue caring for you.

Your Patient Navigator

A dedicated Patient Navigator works one-on-one with you to help coordinate your care needs and get you set up with the Transitional Care Clinic.

We Are Here for You

If you have an appointment scheduled at the Transitional Care Clinic and need assistance or have a health concern before your appointment, call 910.667.6255.

This number will connect you with a team member 24 hours a day.

Insurance and Payment Information

Care provided at the Transitional Care Clinic is covered by all major insurance plans, Medicare and Medicaid. 

If you do not have medical insurance or are concerned about your ability to pay for your medical care, our Patient Access Department can work with you. Our Patient Access team can help answer any questions and guide you through the process of applying for financial assistance you may be eligible for.

What to Expect at My Appointment

Dr. Nicole Charkoudian discusses the importance of receiving care after a hospital stay.


What to Bring to My Appointment

  • Patient Education Booklet (Heart Strong, COPD Patient Education Booklet, etc.)
  • All medications you are currently taking in their original containers, including:
    • All prescription medications
    • All over-the-counter medications, herbal supplements and vitamins
    • Any creams or eye drops
  • Financial assistance paperwork (if applicable)
  • A family member or loved one
    • Please invite any member of your support team who assists with your medications, doctor visits, or other health needs.

Frequently Asked Questions

How often will I need to visit the Transitional Care Clinic?

You will have an appointment at the Transitional Care Clinic once a week, as needed. Once you have connected with a primary care provider at your medical home, you will no longer have appointments at the Transitional Care Clinic.

How long will I be a patient at the Transitional Care Clinic?

Your care team at the Transitional Care Clinic will work with you for 4-6 weeks to give you the support and care you need to help manage your condition.

What happens when I’m discharged from the Transitional Care Clinic?

We will make any necessary appointments for you with the doctor who can best continue your care. Once that appointment is made, you will be discharged from the clinic and will transition to the care of your primary care provider.

Will you tell my primary care doctor about the care I received at the Transitional Care Clinic?

Yes. Your team at the Transitional Care Clinic will notify your doctor of all treatments, tests, and services you received while in their care. Your primary care physician will also have access to your medical records, including all medications prescribed by Transitional Care Clinic providers.

If I don’t have a primary care doctor, will you help me find one?

Yes. If you need help finding a primary care provider or need a referral to a specialist, the team at the Transitional Care Clinic will assist you. Once you have an appointment with your new doctor(s), we will send them your medical records.