Care Transitions

Helping ensure a seamless continuum of care during your recovery! Call us at 509-960-7281 to learn more about this program. 

Care Transitions occur when a patient moves from one healthcare setting to another. These transitions can often be dangerous when there are gaps in support. This free evidence-based program will help you during your hospital discharge to ensure you receive the support and quality of care needed during your recovery at home.

A Care Coordinator will work closely with you during this time to help you navigate complicated medical and social service systems, create a plan to determine necessary supports, and reduce the likelihood of hospital readmissions. Coordinators will work with existing services you may already have set up, and actively advocate for your needs!

How the Program Works:

  • Client enrolls in the program (at no charge). Call 509-960-7281 to learn more.
  • A Care Coordinator will make a home visit and identify client needs.
  • The Care Coordinator will make referrals for community-based resources, including Medication Management.
  • The clients needs will continue to be reviewed and support will be provided as needed.


  • 18 years of age or older
  • Have a serious chronic health condition
  • Recently hospitalized

Who to Contact: For Spokane County, please contact the Community Living Connections Helpline at 509-960-7281.

Note: For Ferry, Stevens, Pend Oreille, and Whitman Counties call Rural Resources Community Action at 1-800-873-5889 or go to