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Transitions in Care

Continuing a Partnership in Caring

At Saint Clare’s Health System, we are continually finding ways to improve your care not only in the hospital, but also after you return home.  Our primary purpose is to make your life healthier and help prevent you from being readmitted to the hospital.  Saint Clare’s offers a 4-week program, called Transitions in Care, which is designed to improve the continuity of care for persons with chronic conditions across different health care settings, and ensure the smooth transition of each change. There is no cost to you or your insurance provider for any of the resources for the duration of your program.4

A Team of Healthcare Professionals
As part of the Transitions in Care program, you will receive support services and guidance from a team of experienced healthcare professionals.

Your Saint Clare’s Transitions in Care team includes:

  • Cardiologists
  • Registered nurses
  • Dieticians
  • Pastoral care
  • Nurse practitioners
  • Social workers
  • Case managers
  • Pharmacists
  • Visiting Nurse Associations and other healthcare partners

Reducing Preventable Hospital Admissions


Transitions in Care services include:

  • A Personal Health Record (PHR) designed to help manage the health condition
  • A home visit from a Nurse Navigator
  • Three follow up calls from a Nurse Navigator
  • Review of patient’s medications
  • Preparations for follow-up appointments with primary care physicians
  • Help to understand the health condition

The service helps your loved one:

  • Recover
  • Understand and manage medications better
  • Help prevent them from being readmitted to the hospital
  • Maintain the good care they have been receiving in the hospital after they get home

For more information or to schedule an appointment, please call (973) 983-5270 or visit saintclares.org.

 

 

 
Page Resources

SPOTLIGHT: Transitions in Care

 

Turning Promise Into Practice