Blessing Health System has implemented care coordination services to help residents navigate local healthcare services. This provides service navigation, chronic disease management and transitional care management. The new transitional care program aids patients at high risk for readmission to the hospital. Once a patient is identified as a high risk for readmission, a nurse care manager or caseworkers will arrange home visits and make telephone calls to address medication management, primary care provider appointment attendance and potential warning signs of a condition worsening.
