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Transitional care team discusses treatment options with a patient

About Transitional Care

transitional care team member with patientAs medical advancements have been made, patients spend less time in the hospital and emergency department and complete more care in outpatient clinics and at home.

Transitional Care is a new area of medicine developed to support patients as they transition from acute care settings to outpatient clinics and home. Though most patient's medical condition does not necessitate long hospital stays, the health crisis that results often requires additional support and can benefit from a detailed evaluation of all the factors that affect a person's health.

The Northwestern Medicine Transitional Care team has expertise in assessing whole person medical and psychosocial needs and addressing them concurrently with onsite multidisciplinary resources to improve a patient’s independence and overall health.

Transitional Care Medicine bridges four systems of care:

  1. Acute Care
  2. Emergency Department or Urgent Care
  3. Specialty Care
  4. Primary Care

During these transitions, our team will connect patients with any available and appropriate support services, while also providing education about their health and how to get the most out of the healthcare system. Our staff will work to empower patients to improve their self-management and efficiently connect to specialist partners as needed.

Our clinic accepts all insurances that are accepted by NMG, and we will also accept patients with limited or no insurance.

Our Mission Statement

  • To improve health outcomes for patients with complex medical and psychosocial needs through an integrated and interdisciplinary team-based approach
  • To provide high-quality, empowering, and compassionate transitional care to reliably and efficiently meet the needs of our patients

Our Values

  • Innovative: To meet the dynamic and ever-evolving patient need
  • Collaborative Community: To empower change
  • Determined Advocates: For patients and policies
  • Responsive: To data and quality indicators to adopt new practices

Contact Us

To schedule a visit at the Transitional Care Clinic, call 312.926.6831.

Transitional Care Providers

Three members of the transitional care team standing in the hallway

The Transitional Care team is made up of medical and mental health providers, social workers, health advocates, and pharmacists who identify and address patients’ needs to provide whole person wrap-around services.

Meet the Transitional Care Team

Locations & Contact Information
    Physician meets with a patient

    What to Expect From Transitional Care

    Transitional Care will help patients manage and understand their health conditions and medications, as well as create a plan to take care of their non-medical needs.