Care Transitions Program

The Care Transitions Program is one of Alameda Health System’s three complex care programs. Together with the Clinic Based Complex Care Management program and the Homeless Coordination Office, the team provides coordinated follow up on some of our highest risk patients.

The teams, which include nurses, community outreach workers and social workers, help to remove obstacles these patients face such as lack of resources and access to needed services. They educate patients on their chronic diseases and assist with such things as making appointments, following up on labs, arranging transportation, while also offering emotional and practical support.

The purpose of these videos is to educate both patients and providers on the realities of managing the day-to-day while living with a chronic disease, and what obstacles and difficulties patients face. Each video is a personal experience, for an individual patient, on what it’s actually like living with a chronic disease. The goal of this project is to exhibit how providers can assist those living with chronic disease, in order that they might lead healthier lives.

The video project featured on this website is made possible by a Spotlight on Success grant from the Gordon and Betty Moore Foundation.

Thaddius Eison 
Patient: Alameda Health System

Thaddius Eison battles complex medical conditions and substance abuse

Donald Butler 
Patient: Alameda Health System

Donald Butler speaks about coming to terms with his new diagnosis, some things that have helped him along the way, and his outlook for the future.

Billy Nivins
Patient: Alameda Health System

Billy faces the complexity of addition, his readiness to change, his road to recovery, and the joy in his new found relationship with his family. 

Jason Robinson
Patient: Eastmont Wellness Center

Jason Robinson struggles with chronic obstructive pulmonary disease, and the challenges he faces in managing  his medications.  

Lorrel Anderson
Patient: Alameda Health System

Lorrel Anderson faces challenges with congestive heart failure. He shares his experience with how the care transitions team have assisted him in the management of his illness. 

Gemeral Young
Patient: Alameda Health System

Gemeral Young struggles with substance abuse and the negative effects on his health. 

Compilation

A short compilation of various stories of patients who were followed by the care transitions program.

Adrian
Patient: Alameda Health System

Adrian battles substance abuse and shares his experience with the care transitions team and their guidance unto his road to recovery.