The care team at Ascension Via Christi Transitional Care Clinic provides short-term healthcare and connects patients with resources to find a primary care doctor. We deliver both in-person and telehealth medicine services. The Transitional Care Clinic was created in 2014 to support patients that are at high risk for emergency room visits and unplanned hospitalizations. If you are unable to find traditional primary care due to social or economic factors, we listen to understand you and your health concerns. Then, we work with you to connect you to a primary care doctor that’s right for you.
Reducing risk of hospital readmission
The Transitional Care Clinic also provides programs to help patients with chronic illness and reduce their risk of readmission to the emergency room.
Community Cares: A program for home-bound patients with chronic diseases that delivers routine and acute care.
Congestive heart failure clinic: Coordinates care and helps improves quality of life for patients living with heart failure
Chronic obstructive pulmonary disease (COPD) clinic: Coordinates care and helps improves quality of life for patients living with COPD
Outpatient stroke clinic: Coordinates care and monitors recovery for patients who have survived a stroke
Post-acute care services after being hospitalized
The transitional care team at Ascension Via Christi is here to support you during your recovery. Our doctors and nurses specialize in post-acute care medicine in an outpatient setting, much like the hospitalists who delivered acute care medicine when you are hospitalized.
We help you focus on your recovery, which includes:
- Getting enough sleep
- Getting proper nutrition, hydration and exercise
- Maintaining good, healthy habits
- Managing your medication routine
- Using wound care supplies
Other post-acute care services may include home health care or skilled nursing. A doctor’s referral is needed for transitional care and other related services.
