Transitional Care Coordination Team

TCC Team 2025

The Transitional Care Coordination Team (TCCT) provides interdisciplinary services pre-discharge and post-hospitalization to decrease adverse events and improve patient safety and satisfaction. Team members help patients obtain appropriate follow-up appointments at the time of discharge while also maintaining open lines of communication with patients and their care teams to resolve any issues that arise after hospitalization.

The care coordinators provide post-discharge handoff to all patients' longitudinal care providers to assure a seamless transition. The TCCT also offers social work case management to those patients at highest risk for readmission.

The team consists of registered nurses, a licensed clinical social worker, a patient navigator, and transition care assistants.