Transitional Care Coordination

The Transitional Care Coordination Program (TCC) is a team that will help patients at risk of readmission transition from the hospital to community-based care.  We meet patients while hospitalized and follow-up via telephone or in person visits for 30 – 45 days as needed. Our program is voluntary and free for patients.

Our Patient-Centered Services

• Pharmacist provides medication reconciliation and individualized medication education
• Nurse helps patient understand their illness and explore ways to stay/become more healthy
• Social Worker assists patient to connect to community resources and work through social barriers to good health

Referrals

• We pride ourselves in our relationship building while patients are still in the hospital and find it helpful if patients are referred early in their hospitalization. Prior to the discharge of a TCC patient, please contact us with ample time in order to obtain their medications and properly educate the patient.  
• For Referrals – Send a Page to the TCC Pager #11211 or call the pager number 410-232—4623 between the hours of 8:30 a.m. – 4:30 p.m., Monday through Friday
• We welcome all adult referrals with the exception of peri-transplant, obstetric, LVAD, and active chemotherapy patients
• Anyone can refer

Please call any member of the TCC team with your questions (messages are retrieved Monday through Friday, 8:30 a.m. – 4:30 p.m.).

Anne Connor, RN
Office phone: 410-328-4167
Email: aconnor@umm.edu
Mobile phone: 443-610-5274 

Sara Eltaki, PharmD
Office phone: 410-328-4166
Email: seltaki@umm.edu
Mobile phone: 443-610-0209
Pager: 410-232-0573/ ID # 11149

Patsy Flanagan, LCSW-C
Office phone: 410-328-4171 
Email : pflanagan@umm.edu
Mobile phone: 443-904-0859

Teresa Fleming, CPhT
Program Assistant
Office phone: 410-328-9047 
Email: tfleming@umm.edu
Pager: 410-232-0275/ ID # 10179