Coronavirus (COVID-19): Important information from Sharp
Doctor's office
Enter your doctor's name to get office information.
Find labs in your network
Enter your primary care doctor's name to find labs in your network.
Find urgent care centers in your network
Enter your primary care doctor's name to find urgent care centers in your network.
Driving Directions
Update Information
Forgot Password

Please enter your e-mail address.

Sharp Health News

Helping patients transition from hospital to home (video)

April 18, 2016

When Gary left the hospital after a brief stay, he had a lot to remember. Between his old and new medications, new guidelines for managing his high blood pressure, and the effects of his four strokes, Gary could have easily ended up back in the hospital, slowing his recovery even further.

Luckily, Gary had Dinah on his side. Dinah David-Quimen, RN, is a health coach with Sharp’s Community-based Care Transitions Program, part of a countywide pilot program to reduce hospital readmission for Medicare patients. She visited Gary shortly after he returned home to help make sure he knew which medications to take and which to stop taking, and to help him manage upcoming appointments.

“I don’t know what I would have done if you hadn’t come in. I’d have been in bad shape by now,” Gary told Dinah, as they reviewed his case at his dining room table.

Gary is one of more than 7,000 patients served by Community-based Care Transitions, according to program manager Cecile Davis, RN.

“First and foremost, Sharp is interested in patient safety,” she says. “We want to ensure that patients have what they need to continue their recovery from their hospitalization.”

Staffed by 10 registered nurses and three pharmacists, the program reaches out to every eligible Medicare patient discharged from a Sharp hospital within three days to schedule a phone call, home visit or both.

“Our goal is to keep the patient at home as this is where their daily life occurs, where their support lies and where they are most comfortable,” says Davis, noting that coaches are trained to work with patients to help them gain the confidence to manage their own care.

“The plan needs to come from the patient,” she says. “Through the intervention, our coaches assist with the creation of a care plan that involves understanding medications, understanding the patient’s disease process — knowing when to call the doctor and when to call 911 for example. We ensure the patient has a primary care physician and that the patient has an appointment within a week of discharge. Lastly, that all of this comes together in a personal health record which is where all this information is organized for the patient to use.”

While hospital staff can send patients home with some of the tools needed for a successful recovery, some elements lie outside the hospital’s influence. In those cases, coaches can refer patients to community-based services.

“Housing, lack of social support, money for co-pays and medication costs are difficult for hospitals to wrap their arms around,” says Davis. “Sending coaches who understand community support and are connected to programs that give patients support at home is imperative. Our coaching teams are a bridge from hospital to community.”

The Community Care Transitions pilot program has ended. A similar program is now available for patients at Sharp Grossmont Hospital.

This story was updated in June 2017.

You might also like:

Choose the doctor who's right for you.

At Sharp, we make it easy to find an exceptional doctor — right where you live and work.

All Categories
Contact Sharp HealthCare
Call us


If this is a life- or limb-threatening emergency, please call 911 immediately.

Email us

Please do not use this form to convey personal or medical information.

How would you like to be contacted?
Date of birth

Find other numbers

View our phone directory

What's This?

These important numbers are located on your billing statement.

Find your Sharp Rees-Stealy account number

Find your Sharp Rees-Stealy account number

Find your Sharp hospital account number

Find your Sharp hospital account number

Find your SharpCare account number

Find your SharpCare account number
What's GDPR?

The General Data Protection Regulation (GDPR) governs the processing of personal information gathered from individuals while they are in the European Union (EU) and parts of the EEA (European Economic Area, which currently includes Iceland, Lichtenstein and Norway).

We are sorry, but we are unable to process hospital price estimates if you live or are travelling within the EU or affiliated nations.

To learn more, call us at 858-499-5901.

What's This?

Many surgery and procedure names sound similar. If possible, please provide the current procedure terminology (CPT) code, which can be found on the order from your doctor.

If you cannot provide the CPT code, please contact your doctor's office for the CPT or a detailed description of services.