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Coordinated Transitions of Care Program

A phone-based intensive transitional care program that bridges the hospital and the Veteran's home, providing education, medication management, and improved communications.

C-TraC Program

The VA Coordinated Transitional Care (C-TraC) program supports vulnerable, elderly Veterans who have a high risk for complications and rehospitalization when transitioning from our hospital to a community setting.

Eligible patients get their own transitional care nurse who provide intensive care coordination.  The C-TraC nurse:

  • Works with the Veteran's medical team to create the best possible discharge plan.
  • Empowers patients and caregivers in medication management.
  • Puts in place additional resources and support, if needed.
  • Educates the Veteran on "red flags" that require a call for help.
  • Ensures adequate medical follow-up.
  • Calls soon after discharge and then weekly as needed.

Patients may call the C-TraC nurse directly during work hours (7:00 a.m. to 3:30 p.m.).

For more information:

Tanya Clayton, RN:;

Ramona Rhodes, M.D.:;