Transitional Care

After hospitalization, patients need rest to heal. But adjusting to a new routine can be exhausting for both patients and their loved ones. In February 2015, Queen of the Valley partnered with Sonoma State University (SSU) and launched the Transitional Care program to ensure patients and caregivers make a smooth and successful transition from hospital to home.

The new program provides an extra level of support by connecting patients, who have been recently discharged from the hospital, with a nursing team. The team, comprised of a Registered Nurse and nursing intern from SSU, become the patient’s “coaches” and guide the patient along the journey to recovery.

The program begins with a nurse visiting the discharged patient’s home. During the visit, the nurse and patient discuss diet and exercise and review the patient’s medications, to ensure past and present prescriptions are reconciled. The nurse also conducts a safety assessment of the home and makes recommendations, such as installing a shower chair or hand rails on stairwells.

Following the home visit, the nurse calls the patient once a week for a 30-day period and is readily available to answer questions, serving as a liaison between the patient and their providers. For more information and to learn more about the conditions covered by the Transitional Care program, call 707-251-2000.