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Transitional Care Team

Transitional Care Team

It can be very challenging to transition from the hospital back home after a mental health crisis. Monarch has a dedicated team of nurses, case managers, and peers who will help individuals to understand their medications, get to medical and mental health appointments, and settle back into life following a stay in the hospital.

What is Transitional Care?

The Transitional Care program is a free service for people with mental health, developmental disabilities, and substance abuse condition(s) who may also have a chronic physical health condition such as diabetes, hypertension or breathing problems and are at risk of unplanned hospital stays or Emergency Department (ED) visits.

The program focuses on follow-up care after you leave the hospital. Our goal is to help you improve your overall health, and to help you understand your discharge instructions and medication routine to avoid returning to the hospital for complications.

The Transitional Care Team (TCT) will schedule to see you at home within a few days of discharge from the hospital. During the visit in your home, you can expect the nurse and case manager to:

  • Check your blood pressure, heart rate, weight, oxygen level
  • Answer your healthcare questions
  • Help you understand your health condition(s)
  • Update your current medication list
  • Help you better understand your medicines and how to take them
  • Help you improve your health at home and in the community
  • Access the services and/or equipment you may need
  • Schedule needed follow-up appointments with doctors

Communicate your health information to your doctors. This service is offered in partnership with The Sandhills Center, Partnership for Community Care and Cone Behavioral Health.

For information about the program, or to ask questions about your home visit, please call (336) 676-6867.

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    Administrative Office: 350 Pee Dee Avenue, Suite 101, Albemarle, NC 28001
    Phone: (866) 272-7826 | Fax: (704) 982-5279