Transitions of Care Program

West Virginia residents face many challenges in receiving necessary medical treatment, from needing to travel great distances for care at WVU Ruby Memorial Hospital, to having limited access to primary care physicians and specialists after returning to their communities.

Designed with these challenges in mind, WVU’s Transitions of Care Program works to mitigate these problems and prevent readmissions by providing support and follow-up communication during a patient’s transition from the hospital to their homes.

Consisting of the Transition of Care Clinic (TCC) and the Transitional Care Coordination Team (TCCT), these multidisciplinary teams provide comprehensive care for patients with complex medical needs through care coordination, medication reconciliation and patient education following hospitalization.