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Transitional Care

VCU Health Transitional Care, established in 2000, is modeled after Mary Naylor’s program in Philadelphia. It involves nurse practitioners that see patients in the VCU Medical Center and then manage their care for several weeks, making home visits and coordinating care, until patients are able to return to their usual clinic providers (or are determined to require permanent enrollment in House Calls).  Enrollment is made on specific referral of high-risk patients from medical center inpatient staff using on-line triggers and pathways.  

Transitional Care Contact Number: (804) 354-8108