What is a Transitional Care Coordinator?

These nurses help patients with home healthcare 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.

St. Joseph’s/Candler offers home healthcare for eligible patients that need assistance in the home whether with a skilled nurse, physical, occupational or speech therapist or medical social worker. Patients may choose their home health provider.

If you choose SJ/C Home Healthcare services, a transitional care coordinator will meet with you and answer many of your questions prior to discharge. A transitional care coordinator can also help manage expectations for those patients leaving the hospital and getting the services of St. Joseph’s/Candler Home Healthcare.

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

“Our main purpose is to transition people from the hospital setting to a home health setting,” says Ashlee Bright, transitional care coordinator at Candler Hospital (on the right in the photo). “I always tell patients our main goal is to keep them from going back to the hospital and keep them well in the comfort of their own home.”

In addition to Bright, we have a dedicated home health transitional care coordinator at St. Joseph’s Hospital. Her name is Susan Bruggeman.

Our transitional care coordinators are responsible for assisting the patient and caregivers in the process of navigating a safe transition from hospital to home healthcare. 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.

“We work really closely with the case workers in the hospital and our schedulers at home health,” Bruggeman says. “We are working together as a team to bridge hospital discharge with home health care.”

Typically, our transitional care coordinators 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.

St. Joseph’s/Candler Home Healthcare 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.

“Some of these patients may leave the hospital and still need IVs or wound vacs, and they’ve never needed that before,” Bright says. “We can come in and educate them about what to expect with home health, and many find it nice to know that somebody is going to be there to help them.”

Additionally, our transitional care coordinators work with existing SJ/C home health care patients if they do have to return to the hospital. They will follow the patient’s progress, and upon discharge, if the patient wants to continue home health care – which many do, Bruggeman says – they will coordinate that schedule.

“I really enjoy talking to and helping the patients and families the most,” Bright says about her role. “Before I was in the office doing authorization so I didn’t see or get much patient interaction for a while, and I’ve been a nurse for 13 years, so I was missing that aspect of it. It’s nice to be able to work closely with patients.”

“I agree; it’s all about helping the patients and families,” Bruggeman says. “Also, I enjoy working with the case managers. We really have a lot of great case managers. They are very helpful.”

“It’s everybody working together to make sure the patient has what they need to go home, and that’s a great thing about our health system.”

Learn more about SJ/C Home Healthcare here