Inova Cares Clinic for Community Bridging was developed to bridge gaps in care that patients experience as they transfer across care delivery settings between illness and recovery. The service focuses on transitional medical care and community collaboration in order to improve health outcomes of patients at the highest risk who lack access to needed resources.
Inova Cares Clinic for Community Bridging seeks to provide services that will enhance the lives of patients so that they may better manage their healthcare and live longer, more productive lives.
We support patients being discharged from an Inova hospital or Inova emergency room who either do not have a medical home or cannot get an appointment with their primary care provider within 72 hours following a hospital admission.
Patients are typically followed by a hospitalist or nurse practitioner for one to three visits, while the patient and the care team work together to establish a permanent medical home in the community for the patient or transition the patient back to their primary care provider.
Care will include:
- Medication Reconciliation
- Medical Management
- Anti-coagulation Management (if needed)
- Referrals to assist with social determinants of health.
Patient referrals to the Inova Cares Clinic for Community Bridging are internal only and coordinated through Inova inpatient and outpatient providers for patients who have had an Inova hospital or Inova emergency room encounter within the last 30 days.
The Inova Cares Clinic for Community Bridging has locations in Alexandria, Fairfax and Leesburg.