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Transitions of Care Program

Last Updated Friday, September 06, 2013 6:31:20 PM


The goal of the Transitions of Care program at El Camino Hospital is to provide patients, their caretakers, and family members a smooth transition between care settings.

Our Team

Our program is comprised of a team of specialists who are trained to work with patients and their families. Our team members include:

  • Acute coronary syndrome clinical nurse specialist
  • Cardiothoracic surgery nurse navigator
  • Geriatric nurse practitioner
  • Heart failure clinical nurse specialist
  • Outpatient case manager
  • Pharmacist
  • Pharmacy technicians
  • Transitions coordinator

What to Expect from the Program

Upon discharge from the hospital the patient will receive follow up by one of our team members. This may include:

  • A free home visit from the outpatient case manager within the first 24-72 hours of discharge from the hospital
  • Access to a pharmacist for medication related questions
  • A nurse to nurse phone report between the hospital and a skilled nursing facility at the time of discharge (if applicable)
  • For patients discharged to a skilled nursing facility, a nurse to nurse phone report will take place between the hospital and the facility at the time of discharge
  • Free elder care consultant services
  • Norma Melchor Heart & Vascular Institute Clinical Nurse Specialist phone counseling and patient education
  • Phone calls from the transitions coordinator to discuss your well-being and provide you with information on community resources

Program Eligibility

Eligible patients will be identified prior to hospital discharge by a team of multidisciplinary clinicians.

Contacting the Transitions in Care Program

To learn more about the Transitions of Care Program, please call Patient Care Services at 650-988-7648.

Transitions of Care Program Brochure

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Transitions of Care Program Brochure