Care Transitions

Purpose:  The Care Transitions initiative partners with area hospitals and organizations to improve communication, collaboration and coordination aimed at enriching care transitions for consumers and families in East Tennessee.

Eligibility:Resident of East Tennessee who is transitioning from one care setting to another (i.e. hospital to home).

Top 3 Goals:

1.   To build and sustain a community coalition with a focus on improving transitions of care for Medicare beneficiaries

2.   To be an advocate for patient and family needs

3.   To collaborate and encourage efforts of organizations with shared visions

Explanation of Services: The term “care transitions” refers to the movement patients make between healthcare practitioners and settings as their condition and care needs change during the course of a chronic or acute illness (i.e. hospital to home). Through partnerships with area hospitals, physician practices, offices on aging, pharmacies, home care and home health agencies, hospice organizations, long-term care facilities, county health departments and others, the Care Transitions initiative is exploring ways to collectively improve healthcare for older adults; thereby reducing unnecessary hospital readmissions.  The “Building a Bridge to Better Health Coalition” was formed to better connect the efforts occurring across the East Tennessee region, and more effectively serve patients and consumers. 

Counties Served:Anderson, Blount, Campbell, Claiborne, Cocke, Grainger, Hamblen, Jefferson, Knox, Loudon, Morgan, Monroe, Roane, Scott, Sevier and Union.

For More Information ContactDottie Lyvers at (865) 691-2551ext. 4818 or by email at