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.
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.).