Transitional Care Services

RWJ’s commitment to improving the health and well-being of the patients and communities we serve doesn’t end when patients are discharged from the hospital. Our Transitional Care Services programs ensure that patients transitioning from Robert Wood Johnson University Hospital to home or a care facility are provided the resources and support that they need to remain on the path to wellness.

What Is Transitional Care?

Transitional Care helps ensure that patients have everything they need to make the transition from the hospital to home as smooth as possible, making sure patients understand how to monitor and manage their health outside of the hospital environment.

If you qualify for the RWJUHDelivery System Reform Incentive Payment (DSRIP) Program services, an advanced practice nurse is assigned to you. Within the first seven days after you are discharged from the hospital your nurse will visit you or see you at the DSRIP Discharge Clinic. Your nurse will also follow up with you weekly to assess your needs throughout the first 30 days after discharge.

If you qualify for our other Transitional Care services, a registered nurse is assigned as your personal Care Transitions Coach. Your coach will visit you 24-72 hours after you are discharged from the hospital and will help answer any questions you or your caregivers may have as you transition to the next setting.

All Transitional Care services can help patients and caregivers keep track of important information including:

  • Symptoms: What to watch for, how to respond, and potential red flags.
  • Medications: What each medication does, plus how and when to take each.
  • Follow-Up Appointments: Help to schedule and prepare, including what questions to ask.
  • Contact Information: For hospitals, pharmacies, primary care and home health providers.

Free Service

All Transitional Care services are provided to eligible Medicare & Medicaid beneficiaries at no cost. Care Transitions Coaches do not provide home care, but eligible patients may receive both services.


Contact the DSRIP Discharge Clinic at (732)-484-2079.
Contact the Transitional Care Services team at (732) 253-3482.

  • Heidye Rodriguez, RN, BSN
    (732) 337-7750
  • Leticia Recinos, RN, BSN
    (732) 768-2811
  • Rita Saunders, RN, BSN
    (732) 215-5975
  • Jackie McKelvie, RN, MSN, MHA
    (732) 299-3592
  • Evelyn Perry, RN, BSN
    (732) 956-4596
  • Connie Bialoblocki, RN, BSN
    (732) 336-9611