• 530.541.3420 | 2170 South Avenue, S. Lake Tahoe, CA

We know it can be difficult as you transition from the hospital into your home care environment. Barton’s Transitions in Care is a voluntary program designed to assist in addressing issues that may arise following your hospital stay including changes to your daily medications, proper treatments and follow-up care.

Specially-trained nursing coaches are dedicated to working with you to co-manage your healthcare needs as you transition back to your home. Our end goal is to empower you with the tools necessary to successfully manage your overall health at no cost to you.

Our care team nurses have undergone specialized training and are experienced in Chronic Disease Management. As your dedicated Care Coach, they will meet with you prior to your hospital discharge and provide complete Transitions in Care program information. Together, you and your Care Coach will determine if the program is right for you.

Patients Who Benefit

The Transitions in Care program is designed to assist those patients who:

  • Have recently been diagnosed with a chronic disease impacting their healthcare needs
  • Are faced with existing chronic disease challenges
  • Take multiple medications, new medications and/or changes to an existing medication regimen
  • Have undergone a recent hospitalization or several hospital re-admissions
  • Visit the Emergency Department several times throughout the year
  • Are treated by multiple clinical specialists or who do not have a primary care provider

Starting Your Care Program

If you decide to enroll in the Transitions in Care program, you will receive a home visit by your Care Coach following hospital discharge.

During your initial home visit, your Care Coach will:

  • Review medications and assist with medication questions
  • Go over your Personal Health Record and address questions
  • Arrange follow-up visits with your primary healthcare provider and/or specialist
  • Provide additional education on disease processes and other areas of concern

After Your Home Visit

Following your home visit, you will receive follow-up phone calls from your Care Coach on days 2, 4, 7, 14 and 30 following your hospital stay to address questions and concerns.

Contact Information

If you have questions regarding our free Transitions in Care program, call 530.543.5688 or email transitionsincare@bartonhealth.org.

This program is modeled after the Care Transitions Program created by Eric Coleman, MD. For more information, please visit www.caretransitions.org.