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Transition Care Management Role & Process

In person and telephonic nurse visits to hospitalized CCH patients

  • Assess understanding of diagnosis and hospital plan of care
  • Educate and coach to promote health literacy and self-efficacy
  • Identify social determinants of health and barriers to care
  • Develop patient centered goals and care plan
  • Provide advocacy, mobilize resources, and connect to services

Actively collaborate and coordinate patient care with hospital care team

  • Facilitate hospital to primary care provider communication
  • Update hospital care manager of TCM hosp visit and scheduled follow up

Coordinate access to CCH integrated care team for medical, mental health, and substance use disorder needs

  • Schedule follow up appt with CCH provider before discharge
  • Inform PCMP of hospital course, summary of care, and follow up needs


  • Coordinate transitions from hospital to community, respite care, and primary care
  • Reduce hospital utilization and readmission through increased primary care engagement
  • Participate in program development and partner collaborations
  • Identify high risk hospitalized clients within primary care population and manage ongoing dynamic panel

CCH Transition Care Management (TCM) Nurses

Kiera Davis, RN Laura Quann, RN Allyn Krzymowski, RN Lauren Butler, RN
Kiera Davis, RN Laura Quann, RN Allyn Krzymowski, RN Lauren Butler, RN