Care Transitions Program
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Care Transitions Program

The Roper St. Francis Care Transitions team understands that people want to have control over their health. The Care Transitions program, the first of its kind in the area, is designed to give you the skills and confidence to manage your health at home and to avoid being readmitted to the hospital including:

  • Managing your medications
  • Follow-up care
  • Identifying worsening conditions (red flags)
  • Your Personal Health Record (PHR)

The program is aimed at individuals who don't qualify for services like home health or hospice care after they leave the hospital but who are still at-risk of a significant health decline.

Qualifications for the Care Transitions Program:

  • 65 years or older
  • Discharged from hospital and sent home as self care
  • Diagnosis of COPD, CHF, cardiomyopathy, chronic respiratory illness or diabetes
  • Three hospitalizations within the last six months
  • Live in Berkeley, Charleston or Dorchester County


Our Team

The Care Transitions team consists of nurse navigators and community health advocates. Our team will help patients recognize signs and symptoms, manage medications and keep a personal health record.



To learn more about how we can help you and/or your caregiver feel more empowered when it comes to managing your health, please call (843) 402-7000.
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