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Hospital Transition Program

The Hospital Transition Program (HTP) helps facilitate fluid transitions from hospital discharge back to the community. Our program is rooted in best practices and research regarding comprehensive assessment of social determinants of health and related interventions.

The HTP initiative hinges on the notion that no singular healthcare or social service provider can fully meet the ever-growing demands of community health on its own. The best approach to providing comprehensive care to combat the complexity of challenges faced by West Virginians today is through strategic community collaboration.

Services We Offer

Social Determinants of Health GraphOur strength is in our ability to lean into our respective expertise and work together to support those with the greatest need by providing these services:

  • Initial meeting with patient during hospital stay
  • Intensive 6-week follow-up support after discharge home
  • Home visits
  • Assessment of home environment and family needs
  • Transportation assistance
  • Utility/rental assistance
  • Food/nutritional assistance
  • Practical chronic disease management education and support
  • Connection to local resources for ongoing support as needed