Northside Hospital Cherokee has expanded its Transitions of Care Program with a new outpatient Transitional Care Clinic to provide immediate post-discharge care to some of the hospital’s highest-risk patients.
When a patient is discharged from the hospital, Northside Hospital Cherokee’s Transitions of Care Program serves to bridge the transition from in-hospital care to the patient's primary care provider. However, many patients do not have a primary care provider or they cannot get an appointment with their provider within seven days of their discharge from the hospital. That’s where Northside Cherokee’s new Transitional Care Clinic can help.
“Our staff can provide immediate follow-up appointments and care and help to establish additional care with other local providers,” said Tonya Gipson, APRN, Northside Hospital Cherokee Transitional Care Clinic.
The new Clinic specifically serves Medicare patients 65 years and older, who are at moderate or high risk for readmission.
“The primary goal is to support the patient’s continued recovery at home, in hopes of reducing their risk of readmission to the hospital,” Gipson added.
A nurse practitioner consults with eligible patients while they are still in the hospital and schedules their follow-up appointments within seven days of discharge. Population health nurses follow up and call patients weekly for 30 days to coordinate care and answer additional health-related questions.
For more information about the Transitions of Care Program please call 404-845-1681.