Transitions of Care

The Transitions of Care program provides education, resources, and care coordination for vulnerable adults residing in San Mateo, Santa Clara, or Alameda counties. Once a referral is placed by a hospital clinician, patients are offered services for up to 60 days after they are discharged from Stanford Hospital or from post-acute facility, to home. The Transitions of Care team includes nurses, social workers, a geriatrician, a pharmacist, and an occupational therapist.