Transitional Care


Bluebirds Transitional Team works with each teams interdisciplinary group to ensure all your needs are being met through all Bluebird service lines.  Both internally and externally Bluebird Health specializes in bridging levels of care through our pro-bono post-discharge care management program. Nurse Navigators communicate with hospitals, health plans, facilities, and/or other providers involved to ensure patient centered care. If you have any questions about where to start, our Transitional Team is a great place to start! Contact us here!

Transitional Care Goals:

  • Ensure patients have the education and resources needed to avoid trips to the Emergency Department
  • Maximize the in-home benefits that patients qualify for under their insurance plan
  • Provide the highest level of customer service
  • Provide the highest level of communication fostering continuity of patient care across the healthcare system.

Transitional Care Team:

  • Nurse Navigator
  • Nurse Practitioner
  • Care Coordinator
  • Bluebird Support Team

TCM Program Tenants

  • Transitional Weekly Care Conference
  • Nurse customer service follow up calls at 2, 14, 30, 45, and 90 days
  • Cortex Transitional Software Platform
    • Integrated with Collective Medical and Bluebird EMR to capture hospitalization and emergency department notifications
  • Medalogix, Homecare Homebase, Strategic Health Partners platforms to identify clinical markers for proactive identification of care needs
  • 24/7 On-Call Staff
  • Skilled facility direct admissions
  • PCP or Specialist follow up verifications and orders
  • Nurse Practitioner 7 day visits
    • Medication reconciliation
    • Timely initiative of care outcomes
    • Improved clinical oversight
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