About Us
The Transitions of Care Center is here to help make the transition from hospital or urgent care to ongoing healthcare as smooth as possible. We provide short-term follow-up care for patients who have recently been discharged from an inpatient stay at Tallahassee Memorial Hospital or seen at a TMH Emergency Department or Urgent Care Center and may need additional support after their visit.
Your Care Team
Our dedicated care team includes an:
- Advanced Practice Registered Nurse
- Board-certified Pharmacist
- Health Navigator
During each visit, patients will see all three providers as part of one coordinated appointment. Because patients meet with multiple members of the care team, appointments may take longer than a typical office visit.
Services and Support
Whether patients need short-term medical management, medication review and assistance, help overcoming barriers to care, or support connecting with a primary care provider or specialist, our team is here to help.
Services may include:
- Assistance with filling prescriptions
- Performing lab work
- Arranging physical therapy and other rehabilitation services
- Connecting patients with community agencies and other resources that may be able to provide additional support
Before Requesting an Appointment
Our clinic is designed for patients who recently received care through TMH and need short-term follow-up because of:
- Medical needs after discharge
- Barriers to care
- Difficulty accessing timely healthcare services
If you have health insurance but do not have a PCP, calling the Member Services number on the back of your insurance card is often the fastest way to find or be assigned to a provider.
If you are unsure whether the Transitions of Care Center is right for your situation, please contact our office. We are happy to help guide you.
Frequently Asked Questions
View the Transitions of Care Center Frequently Asked Questions (PDF)
Our Commitment
Recovering after a hospital stay can be stressful and confusing. We are committed to helping eligible patients receive the right care, at the right time, and in the right place.
Whether you need a medication review, short-term medical monitoring, help navigating healthcare services, or assistance connecting to ongoing care, our team is here to support your recovery.
Our goal is to provide timely, short-term medical care that bridges gaps in care and helps patients transition successfully to long-term healthcare providers.
