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The Transition of Care Team Model Overview

Senior Asian Couple Adults with Medical Staff at Home
Wednesday, November 28, 2018

Covenant Plainview Hospital in Plainview, Texas, employs a transition of care team model to prevent readmissions in high-risk patients by: 

  • Having created a risk assessment, performed daily to identify patients at highest risk for readmission.
  • Ensuring bedside nurses follow patients after discharge by visiting them at home within 24–48 hours of discharge. Goals during this visit include education on medications and disease process and resource assessment to ensure post-acute follow-up care.
  • Establishing population health/community partnerships which include monthly meetings with local nursing homes, home health agencies, pharmacies, medical equipment companies, etc. The goals are to identify and mitigate risks/barriers in order to improve the health of the community. 

For more information on Covenant Plainview Hospital's transition of care team model, please contact Rachel Prutzman, RN, Nurse Manager of Acute Care Services, at