Helping you transition from hospital to home
At discharge from the hospital, your Ascension Medical Group Saint Thomas Midtown care coordinator in Nashville, Tennessee may tell you about an outpatient transitional care clinic that is recommended for your initial care immediately after hospitalization. The transitional care team does not take the place of your primary care doctor and is offered as part of our Ascension Medical Group “Continuum of Care” services. During the initial weeks after surgery or a procedure, some patients with complex health conditions are more medically vulnerable. Our clinic delivers personalized, compassionate care for many conditions, including COPD, heart failure, recent heart or lung surgery or a serious respiratory illness.
Post-acute care services
Our transitional care team at Ascension Medical Group Saint Thomas is an active participant in your recovery. Our doctors and nurses specialize in post-acute care medicine in an outpatient setting, much like the hospitalists deliver acute care medicine when you are hospitalized.
Transitional care means you are monitored in the clinic and at home with telehealth monitors on a daily basis for the first 30-days post-discharge. We also make sure you are:
- Getting enough sleep
- Managing your medication routine
- Getting proper food intake, fluids and exercise
- Using wound care supplies
Our care team helps you make a healthy transition from hospital to home and have good daily habits that help improve your recovery. Our doctor may also make a recommendation to your primary care doctor regarding other post-acute care services such as home healthcare or skilled nursing, if needed.
Patients need to be referred to the Transitional Care Clinic by their doctor.