SLCH Patient Stories: Keith Day The more we manage Keith's care, the more he manages to keep out of the hospital.

"I used to be very active, I hiked, kayaked, mowed the lawn. Once I got sick, that all came to a screeching halt. I caught a respiratory infection and got as sick as you can be, and still be alive. The Care Transitions team at St. Luke's Cornwall Hospital stepped up to the plate for me. I was so lost. My nurse, Kathy, took me aside and explained the things I can do to get healthier, out of the hospital and back home. She helped me make phone calls, wade through the mounds of paperwork and work with my other doctors. I have Kathy on speed dial, and because of the Care Transitions team at St. Luke"s Cornwall Hospital, I know I"m not alone."

the slch care transitions program



With recent changes in healthcare law, organizations are striving to provide quality, cost-effective care while achieving the best possible outcomes for their patients.

One important focus is navigating or “transitioning” the patient through the healthcare system. This process assists patients in gaining access to the next optimal level of care and ensuring they find the appropriate venue and services to fit their individual needs.

Since it’s inception in 2012, the Care Transition Program at St. Luke’s Cornwall Hospital has helped achieve reductions in readmissions for congestive heart failure (CHF), acute myocardial infarction (heart attacks) and pneumonia. Before the CTP program began, SLCH experienced a 24 percent readmission rate among CHF patients. Working closely with those patients, the Care Transitions Program has helped reduce that rate to less than 12 percent.

The Care Transitions Program Team consists of Care Transition Program Registered Nurses (CTP-RN), Health Care Coaches (CTP-C), A Multi-Disciplinary Healthcare Team, A Community Care Coalition, and Community Resources

what does the care transitions program do?

Using the Coleman Model of Care Transitions©, the RN evaluates the patient’s current health status and establishes a plan for meeting the goals of The Four Pillars®.

Pillar No. 1

Medication Self-Management" The patient is knowledgeable about their medications and has a system in place to ensure they are taken correctly.

Pillar No. 2

Dynamic Patient-Centered Record: The patient understands and manages a Personal Health Record (PHR) to help manage health goals, appointments, questions for providers and medications.

Pillar No. 3

Follow-Up: The patient schedules and completes follow-up visits with Primary Care Providers and Specialists.

Pillar No. 4

Red Flags: The patient is knowledgeable about signs and symptoms that their condition is worsening, and understands what to do.

The patient navigates through the pillars via an individualized care plan that is designed by the Care Transition Program RN. The patient’s completion of the Care Transition Program is contingent upon their ability to self-manage their condition (or demonstrate family management).

There are no costs for the services rendered through the Care Transition Program.


Patients may be referred to the Care Transitions Program through several sources, including the hospital, their physician’s office, a skilled nursing facility, home health agency or by the patient.

Hospital Staff

Patients requiring hospital services may be identified by healthcare professionals as candidates for the Care Transitions Program based on their current condition.

Physician’s Office

A primary care provider may identify a patient that would benefit from the services of a Care Transitions Program. Similar to the hospital, this referral is based on the patient’s current condition and their ability to independently manage their health issue.

Skilled Nursing Facility (SNF) or Home Health Agency (HHA)

Patients residing in skilled nursing facilities or using home health agency services can be recognized as being able to benefit for Care Transition Program services.


Patients may choose to take advantage of the Care Transition Program’s services on their own based on their perceived healthcare needs.


There is no single, defined time that the Care Transitions Program is appropriate for every patient. Based on each individual’s own circumstances, there are different levels of CTP services to consider.

Acute Level

This experience may be a one-time event in which services are provided, but may not require any follow-up care.

Intermittent Level

This experience may be spaced over periods of time due to a chronic or near-chronic condition. When these periods of illness occur, it may cause a patient to require services on a intermittent basis.

Chronic Level

The chronic experience consists of a more structured and timed approach to interaction with the Care Transitions Program. Examples of chronic illnesses that would require this level of care include congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) and end stage renal disease (ESRD).

Palliative/Hospice Level

This experience may be supportive or comforting in nature depending on the patient’s needs and where they are in their continuum of care.


St. Luke’s Cornwall Hospital Care Transition Program General Information

(845) 568-2190

Care Transition Program RNs

Maureen Monahan, RN:

Kathleen Liston-Scott, RN:

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