A Patient-Centered Medical Home

Care Coordination

If you have a serious or chronic illness or injury, our Complex Care Coordination program can help you navigate through the health care system and provide support along the way. Our Social Work and Nurse Care Coordinators will:

  • Work closely with you and your provider to help you follow your treatment plan
  • Coordinate necessary services
  • Contact or visit with you regularly to see how you are doing
  • Make sure you understand your medications
  • Answer your questions

Transitions of Care

When you are discharged from the hospital or rehabilitation center, your focus should be to get better. That’s why Thomas Chittenden Health Center has our Transition of Care Program to help you on the road to recovery. Our Social Work or Nurse Care Coordinator will reach out to you after discharge to ensure you have the support you need. They will:

  • Help improve communication between you, your providers and other caregivers
  • Offer you support and guidance
  • Connect you with services and programs that can help with your recovery such as physical therapy or home nursing
  • Help minimize or eliminate the need for future emergency room visits and hospitalizations
  • Assist you in understanding your medications including possible side effects

Whether it’s a temporary setback or related to a long-term health condition – our Care Coordinators are here to help.