Transitional Care Program at Rutland Regional

Rutland Regional Medical Center Transitional Care Program helps adults with chronic illness return home safely. We bridge services between the hospital to home by creating partnerships between patients, caregivers, family members, and Registered Nurse. As a team we work to promote recovery, good health and help to find resources to make coping with illness easier.

How Does the Program Work?

The Transitional Care Program is free to all patients who are part of the Rutland Regional Health System. Patients who are recently discharged from the hospital and need additional support are the main focus of the program. Patients may receive phone calls, visits while in the hospital or Emergency Room, at provider offices or clinics, and at home or a place that is comfortable to meet. The program works when patients and families partner with their Nurse. Together we talk about your health and challenges you may have which can affect you and your health.

What Can You Expect?

Depending on your medical conditions your Nurse may:

• Take your vital signs including your weight and check your oxygen
• Perform a physical exam and assess your overall health
• Review and teach you about your medications and make sure your medication list is up to date
• Review discharge instructions you received in the hospital
• Help identify additional services that you may qualify for to help you with food, fuel, housing, or insurance

Patient and Family Benefits:

• The same Nurse will work with you through your entire time with the Transitional Care Program
• Help you avoid a return to the hospital for a chronic illness
• Help finding resources to promote independence and wellbeing to make things easier at home
• Help you review your healthcare wishes and goals by completing an Advance Directive

You and your family are encouraged to call and ask questions or meet with us at a home visit; we want to help you be well.