What is a Transitional Care Coordinator?

These registered nurses help patients with home health care before they even leave the hospital

Being discharged from the hospital typically implies good news for most patients. For some, it also may mean a new routine, new medication and lots of questions.

A Transitional Care Coordinator can answer any questions and manage expectations for those patients leaving the hospital and getting the services of home health care. 

Gerald Hill
Gerald Hill, St. Joseph’s/Candler Director of Home Health Care

St. Joseph’s/Candler offers home health care for eligible patients that need assistance in the home whether with a skilled nurse, physical or occupational therapist or social worker. Patients eligible or interested in home health care may be referred to a Transitional Care Coordinator prior to their discharge from the hospital.

Related Article: How do you know if you or a loved one qualifies for home health care? 

Transitional Care Coordinators are responsible for assisting the patient and caregivers in the process of navigating a safe transition from hospital to home health care. They do this by:

  • assessing the patients’ and caregivers’ areas of need, such as medical equipment, medication, social and emotional issues, transportation or meals;
  • providing information and education regarding what services are available and beneficial; and
  • coordinating the implementation of those services.

“They function as a trusted point of contact for that patient and caregiver for any questions or concerns,” says Gerald Hill, St. Joseph’s/Candler Director of Home Health Care. “This relationship results in less anxiety and stress for the patient and family as they now know exactly what and when things will happen when they get home.”

There is one Transitional Care Coordinator at each hospital. Kelly Wingate is at St. Joseph’s and Helen Slaven works at Candler. These nurses meet with patients after receiving a referral from a case manager or at the request of another staff member who has a patient interested in home health care.

Home health care is a great option for patients wanting to avoid extended hospital stays or time spent at a skilled nursing facility. Home health care is typically less expensive and more convenient, and patients tend to be happier and more at ease in the comfort of their own home, Hill says.

St. Joseph’s/Candler Home Health Care takes a total-patient approach to treatment, meaning we develop specialized plans of care that are most appropriate for each patient’s individual needs and level of functioning. This often begins with the Transitional Care Coordinators.

“How I explain it to patients is if we put a home health nurse in place when they go home then we can be the eyes and ears for the doctor, and we can also give the patient and family a resource that they can keep tapping into knowing we are out there a few times a week checking on the patient,” Slaven says.

A lot of the Transitional Care Coordinator’s job is explaining home health and correcting any misconceptions. For example, Slaven says a lot of patients think a home health nurse will move in and be present around the clock. That’s not the case. Depending on a patient’s condition, he or she may see a home health nurse once a week or three times a week. The length of service also varies and can be as short as two weeks or as long as a couple of years, Slaven says.

Helen Slaven
Helen Slaven, Transitional Care Coordinator at Candler Hospital 

Related Article: Six myths about home health care

“There’s so much anxiety before people go home, and it means so much that I can go in a day or two before and let them know we got this,” Slaven says. “People are a lot happier about leaving and going home if they know that support is already set up and ready to go.”

What is the impact of home health transitional care for patients?

St. Joseph’s/Candler implemented Transitional Care Coordinators about two years ago. The main goal is to cut back on hospital readmissions and/or trips to the emergency department. The cost of an ED visit and one over night stay is the equivalent of four months of home health, Slaven says.

Other benefits to transitional care include:

  • Higher patient satisfaction resulting from better communication – increased knowledge and decreased stress/anxiety
  • Improved and more timely patient care and better outcomes
  • Quicker recovery time post-hospitalization
  • Lower healthcare costs

“Change is hard, especially after surgery, an illness or a new diagnosis,” Hill says. “Patients are sometimes in a vulnerable state, both physically and emotionally, and therefore retention of and the ability to understand and process information may be significantly reduced. Transitional Care Coordinators become the bridge for information before the patient leaves the hospital on how things will occur once home.”

If you think you or a loved one would benefit from a visit from one of our Transitional Care Coordinators, talk to your case manager or a nurse.

To learn more about St. Joseph’s/Candler Home Health Care, visit our website or call 1-800-942-5232. 

  • St. Joseph's Hospital Campus: 11705 Mercy Blvd., Savannah, GA 31419, (p) 912-819-4100
  • Candler Hospital Campus: 5353 Reynolds St., Savannah, GA 31405, (p) 912-819-6000
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St.Joseph's Hospital Campus: 912-819-4100

Candler Hospital Campus: 912-819-6000