My, are times changing. It wasn't that long ago that the great majority of care was delivered in the acute care setting. Now, and as I have written on my blog for the last year, care can be delivered in so many different settings. Today, I am blogging about a concept that the Western Maryland Health System and six other hospitals in Maryland are pursuing, Transitional Care. The focus would be to target high-risk patients, primarily those patients with pneumonia, heart disease, diabetes, COPD and other chronic conditions. Nurses function as caregivers, coaches and navigators. They meet with patients before they are discharged from the hospital and then after discharge in the patient's home. These Transitional Care Nurses make sure that the patient is set with their medications prior to discharge, appointments are set for follow up once the patient is discharged, transportation to doctor's appointments is available and that the patient is appropriately caring for himself to avoid readmission. Most of the seven hospitals noted above are performing some form of transitional care, but by collaborating on such a venture, we could bring best practices to the program, benefit from the economies of scale through less duplication and potentially serve as a model for Maryland. At WMHS, we have already demonstrated that case managing patients and bringing that personal touch to their care can not only reduce needless admissions, readmissions and expensive testing, but it can also reduce the cost of care and improve the quality of the care that is being delivered.