Transitional Care Clinic

Transitional Care Clinic

The Transitional Care Clinic is committed to helping heart failure patients improve their quality of life through education and encouragement.

A skilled team of professionals works closely with patients to develop an individualized treatment plan based on medication compliance, diet, exercise, and lifestyle changes.


Transitional Care Clinic

Melissa Rehkemper, NP-C, explains that Memorial's Transitional Care Clinic sees patients with chronic disorders like heart failure and lung disorders such as COPD. The clinic is in between both the provider and patient going home. The team at the Clinic makes sure that the patient is doing well and that they have all the resources that they need to have a high quality of life. They work closely with the patient's healthcare provider—whether it be pulmonologist, cardiologist, or primary care provider—and collaborate with them to make sure they have all those resources.

When do patients first come in contact with the Transitional Care Clinic?

Shannon Abram, RN, discharge transition coach describes the process, "When they come into the hospital with the diagnosis of heart failure, we see them on the floor; we do intensive education to try to make sure they know what to do when they go home to take care of themselves. That may involve things like getting them outside services too like home care, palliative care, help with medications, help with insurance."

The Clinic even has a pharmacist on staff to assist with patients.

"I see the patients usually shortly after they're discharged from the hospital and then every couple weeks thereafter," says Lauren Eversgerd, pharmacist. "When they're discharged from the hospital, we like to go over their medicines, make sure nothing got missed on the discharge process. These patients are seeing multiple providers to where we making sure they're on all appropriate medicines that aren't going to interact with each other you have any problems. I also like to sit down with the patients and explain to them why they're taking all of these medicines because some of them are like, 'Well, can I just take one blood pressure pill? Why do I need five?' and so it's really about how we can empower the patients to help teach them to take care of themselves and make sure they know the why of why we're doing everything that we're doing for them."

Because diet is such an important part of a heart-healthy lifestyle, the team also includes a dietitian.

Registered Dietitian Pam Nicholson explains, "The first thing we do is visit the patient and do what we call a nutrition history so we can assess what habits are, what they usually eat at home, what's available to them at home, and what their living conditions are...like is somebody there to cook for them, do they do their own shopping, just where do they get their foods. And then from there, we just intervene to help teach them what heart healthy eating is. You know if this is a normal food that you're used to having do we need to make some changes, make alternate suggestions of things to focus in on for their food choices. It is a very big change because the main focus for a heart failure diet is sodium and that changes the taste of the food dramatically is a good word. A lot of people are resistant to that, but hopefully we can explain to them the whys and wherefores of why they're being tortured into a special diet. Yes, I think it does take time for their taste buds to readjust, and we always try to encourage that they just give the whole idea time try, to give them lots of seasoning ideas beyond using a sodium based product. There's lots of herbs and lots of spices and things that we could do an alternative way and try to encourage them to have an open mind about it."

What do you enjoy most about working in the Transitional Care Clinic?

"Being able to build a relationship with my patients," says Melissa. "Getting to know them on a one-on-one basis, and that's just really what attracted me to this position. And providing patient education has always been my love and passion, so I love educating patients and just getting to know them and sitting down and talking."