Transitional Care at Dignity Health Medical Group

Chronic illness patients discharged from the hospital often have questions like:

• “The hospital doctors prescribed different medications. How long am I supposed to take them? What about medications previously prescribed?”
• “I still feel sick and have a new symptom. Could this be a sign my health is getting worse?”
• “The doctors and nurses talked about changes to my diet. Is it possible that the foods I like may have a negative impact on my health?”

The Center for Transitional Care has the answers to many of these questions and is structured specifically to support chronically ill patients who have recently been discharged from the hospital. To assist with these issues and alleviate the stress of navigating these waters alone, a Center for Transitional Care was established at both St. Joseph's Hospital & Medical Center in Phoenix and at Chandler Regional Medical Center in Chandler, AZ. The dedicated providers within these centers help patients get the medical care and information they need to successfully transition from the hospital to properly managed care at home.

Here to Support You

Our multidisciplinary team focuses on the biological, psychological, and social determinants of your health. If a patient is selected prior to hospital discharge for treatment at the Center for Transitional Care, a team member will visit the patient’s room to explain the benefits. To ensure timely follow-up care, an appointment with our team may be scheduled prior to hospital release. Patients can be seen at either DHMG Transitional Care – St. Joseph’s in Phoenix, Arizona or at DHMG Transitional Care – Chandler Regional in Chandler, Arizona.

Benefits of Remote Care

Managing chronic illness to “stay healthy” often requires daily medication and attention to signs and symptoms of disease. Communicating this important information between patient and their primary care provider (PCP) is a crucial step in managing a patient’s health.

The Center for Transitional Care may set up a remote care monitoring system to help health information flow back to the provider from the patient. The benefit is that the patient actively manages their disease and communicates important information to their PCP between appointments. This simple idea includes written instructions as well as a patient checklist. Patients may also receive a scale and blood pressure cuff with instructions on how often to record their health data and how to best report it back to their PCP.

The typical timeline for treatment at the Center for Transitional Care is 30-45 days, at which point their care is transitioned to a primary care center. During this transition, our team will communicate with a patient’s existing PCP or help find a PCP if needed.